pgy-1 program objectives – intensive care rotation - Faculty of ...

PGY-1 PROGRAM
OBJECTIVES – INTENSIVE CARE ROTATION
At a time when few things are called by their right names when it is against the
Spirit of the Time even to hint that an act may entail consequences when you
are going to join a profession in which you will be paid for telling a man the truth,
and every departure you may make as a concession to man’s bodily weakness,
and not to your own mental weakness.
Rudyard Kipling (1865-1936)
Overview
University of Calgary specialty and family medicine residents at the Rockyview General Hospital, currently
receive their Critical Care medicine training during a four week rotation in the intensive care unit.
It is recognized that the ICU may be an intimidating environment to the junior resident, potentially limiting
the educational value of the rotation. It is important that the junior resident develop an approach to the
evaluation and management of complex multi-system medical problems. The proposed objectives are
designed to provide first year specialty and second year family medicine residents with four weeks of
critical care training. It emphasizes problem solving and clinical skills taught at the bedside. With it’s use
of technology, the ICU has a unique ability to bridge academic and clinical science, demonstrating applied
human physiology, pharmacology and disease states.
Regardless of future career paths, the knowledge and skills attained from an ICU rotation will be
invaluable to the care of sick patients in the future.
The following educational objectives have been adapted from the University of Calgary, clinical clerk
Critical Care Medicine curriculum, developed by Steven R. Lopushinsky and Dr. Andre Ferland.
Objectives
There are four stated reasons for incorporating learning objectives into an ICU based critical care rotation;
1) most residents are ill prepared to handle the complex medical and emotional stresses of intensive
care, 2) the difficulty teaching many ICU problems outside the intensive care unit, 3) established
objectives ensure residents are not lost in the shuffle, 4) guarantee that residents are taught essential
critical care topics.
The identified learning objectives involve the cardiovascular, pulmonary, neurological, renal and gastro
intestinal systems. In addition infectious disease, nutrition and medical ethics are included in the
objectives.
The long term goals, objectives and expectations of the resident at the end of the 1 month rotation are:
a) interpret, integrate and apply data from the clinical evaluation, laboratory, diagnostic imaging
and prioritize the patient’s problems
b) present patient’s admitting workup, diagnosis and course in a complete and well organized
manner
c) present differential diagnoses and justify these diagnoses from the data
d) select appropriate investigations and recommend therapy, justified by data
e) evaluate patient response to therapy
f) respond appropriately to changing data
g) develop an understanding of the appropriate use of ICU resources

h) explain the ethical issues and offer solutions to ethical problems involving patients in the
intensive care unit
i) critically appraise literature
The short term objectives are identified to serve as a daily guide to rounds and patient care, to ensure
long term educational objectives are met.
Core knowledge, skills and learning objectives for a resident during the 1-month critical care medicine
rotation include:
1. Respiratory Disease
a) Applied physiology
b) Normal arterial blood gases
c) Differential diagnosis and diagnostic approach to respiratory distress, acute hypoxemia, and
hypercarbia
d) Management of respiratory distress (i.e. acute pulmonary embolism, upper airway obstruction,
status asthmaticus, pneumonia and ARDS)
e) Indications for intubation and mechanical ventilation
2. Cardiovascular Disease
a) Applied cardiopulmonary physiology
Determinants of cardiac output and the principles of oxygen delivery
Determinants of myocardial oxygen consumption
Understanding of preload, after load, and contractility
Role of vasopressors and inotropes
b) Hypotension
Differential diagnosis of circulatory shock (cardiogenic, hypovolemic, obstructive, and
distributive)
Diagnostic plan and management
c) Arrhythmias
Recognition and management of supraventricular and ventricular arrhythmias, including
assessment of precipitating cause
d) Myocardial infarction
Recognition and initiate therapy for acute MI and identify potential complications
3. Neurology
a) Applied physiology
b) Altered mental status, status epilepticus, stroke syndromes
4. Renal
a) Applied renal, fluid and electrolyte physiology
b) Acute renal failure and/or oliguria
Differential diagnosis, diagnostic approach, and management
c) Indications for emergency dialysis
d) Acid-base and common electrolyte disturbancesDifferential diagnosis, diagnostic approach,
and management
5. Gastrointestinal
a) Applied gastrointestinal and hepatic physiology
b) Acute abdomen
Differential diagnosis, diagnostic approach and management
c) Gastrointestinal hemorrhage
Differential diagnosis, diagnostic approach and management
Indications for endoscopy
d) Liver Dysfunction
Hepatic encephalopathy: Differential diagnosis, diagnostic approach and management

6. Hematological Disease
a) Applied hematological physiology
b) Coagulopathy
Differential diagnosis, diagnostic approach and management
c) Anemia
Indications for blood and plasma products
7. Infectious Disease
a) Applied physiology and microbiology of common infections in the ICU.
b) Fever
Differential diagnosis, diagnostic approach and management
c) Nosocomial pneumonia and catheter-related infections
d) Appropriate antibiotic selection
8. Metabolic/Nutrition
a) Principles of nutrition: enteral and parenteral
b) Evaluation of nutritional status and how this differs in the critically ill patient
c) Disorders of sodium or glucose imbalance
9. Pain and Psychosocial
a) Principles and pharmacology of sedation, anxiety and pain management
b) Recognize and manage the psychosocial aspects in the care of patients and families
during acute catastrophic illnesses.
10. Ethical decision making
a) Principles of patient autonomy and informed consent
b)..Purpose of Advanced directives and goals of care
c) Principles of withholding and withdrawing therapy
d) End of life discussion
11. Procedure objectives
Develop basic competence in:
a) Central venous access: internal jugular, subclavian, femoral veins
b) Endotracheal intubation
c) Arterial line insertion: radial artery, femoral artery
d) Chest tube insertion
e) Electrical cardio version
Program Description
Clinical Activities
The rotating resident is expected to attend daily ICU rounds prepared to present their own patients and to
participate in the discussion of all patients. Discussion should include prioritizing the patient’s problems,
differential diagnoses, therapeutic recommendations and investigations. Each day rounds will include
diagnostic imaging. During the rotation, residents should come to recognize common and life-threatening
x-ray findings. Following rounds, the student is expected to carry out the patient care plan as agreed upon
by the multi-disciplinary team.
Should a patient require any invasive procedures, these may be done only at the discretion and under the
guidance of more senior team members. Procedures will be performed independently only after
demonstrating the necessary competence to a CCM resident or faculty.
Formal Educational Activities
In addition to the direct one-to-one teaching by faculty and critical care residents on daily bedside rounds
and in the evaluation of new patients admitted to the ICU, rotating residents will also be exposed to
several formal educational activities:

a) Bedside Rounds
Occur daily at 1000-1200h and 1700h
b) Residents are expected to attend didactic Teaching Sessions, which occur every Monday
and Friday from 0800-0900h via teleconferencing in the ICU classroom. This lecture series
repeats on an 8-week rotation
c) ICU Crash Course
The first day of each 4 week block includes the ICU Crash Course which is held in the PLC
ICU Classroom. This course is mandatory and you are to attend this at the start of or before
your ICU rotation.
d) ICU Grand Rounds
Occur every Wednesday from 0830-0930h via teleconferencing in the ICU classroom.
These rounds are considered mandatory even though rotating residents are not the primary
target audience.
An ICU pocket handbook is available to you on loan for the duration of the rotation. These can be
picked up at the ICU Administration at the beginning of your rotation. A $20.00 deposit is required which
is refunded when the item is returned at the end of the rotation. Please see Joan Emery who can be
reached at 943-3788.
Responsibilities:
The rotating residents will be given graded responsibility in relation to their core knowledge, cognitive and
technical ability. It is presumed that the resident will be capable of caring for 2 to 3 patients daily. Critical
care residents, fellows and intensive care staff will guide diagnostic and therapeutic goals. Call duties
may include responsibilities within the intensive care unit, emergency room or ward as deemed
appropriate by the ICU attending.
The resident’s daily responsibilities include:
a) Being the patient’s primary care physician.
b) Admitting patients to the Intensive Care Unit after an appropriate history and physical
examination has been performed and discussed with the ICU attending physician on-call. All new
admissions will have a set of ICU admission orders entered in SCM.
c) Completing consults directed to the ICU.
d) Attending rounds every morning with the ICU team unless post-call. Providing ongoing care and
management of the patient including, performing a pertinent physical examination daily.
e) Writing a progress note with an emphasis on the patient’s problems, planned treatment and daily
goals of therapy. For post-call residents this must be done prior to the 0800 hr handover.
f) Reviewing laboratory tests each day and signing off laboratory results. Anticipating the patient’s
need for future blood work and x-rays and entering the orders in SCM. “Daily” orders may be
written on patients while they are critically ill, but, must be reassessed on a daily basis.
g) Physician to physician notification when transferring patients out of the ICU. The nurse clinician
will be informed once this has taken place.
h) Dictating discharge/transfer summaries on all patients leaving the ICU. Revising the patient’s
orders will be prior to transfer.
i) Taking part in the call schedule.
j) Taking part in family meetings.

k) Assisting the cardiac arrest (Code Blue) team leader. The attending physician on-call will act as a
resource person.
l) Assisting the Code 66 team leader. This team is designed to assess and initiate management for
unstable ward patients that may or may not require ICU admission.
Guidelines for a resident’s daily responsibilities:
0800 hours Resident(s) to see and evaluate patients, including a pertinent physical examination
and review of investigations
The post-call resident will verbally hand over care of their patient(s) to the resident(s)
remaining that day. The post-call resident will have seen and examined their patient(s)
and have written a daily progress note with an emphasis on the plans and goals for their
patient(s) prior to the handover of care, to ensure continuity of care
1000 hours ICU Bedside Rounds
All residents, who are not post-call, will attend these rounds, which are designed to
review in detail the patients. These rounds are to provide individual teaching in the
Oslerian tradition surrounding the patient’s day-to-day management. They will include
discussion of principles of assessment and diagnosis, underlying physiology and the
basis of treatment of patients.
These rounds involve a multidisciplinary team including nursing, respiratory therapy,
physiotherapy, pharmacy, dietary, and social work.
1700 hours Evening bedside Rounds
Residents, who are not post-call, will attend these rounds, which are designed to followup
on the plans and daily goals defined in morning rounds, review results of new
investigations or new problems arising during the day. The care and goals for the patient
during the night will be determined and handed over to the resident or bedside extender
on call.
2200 hours Bedside Rounds
A bedtime round by the on-call resident is expected and is used to review the patients’
condition and which therapeutic goals have been met. Goals and plans will be adjusted
as needed for management through the rest of the night.
Evaluations
Rotating resident evaluations based on the rotation objectives and responsibilities occurs at the end of
every rotation as per the standard In Training Evaluation Report (ITER). This evaluation will include input
from all attending physicians, fellows, and nursing unit supervisors with whom the rotating resident has
worked. Personnel feedback prior to the final evaluation can be sought by the resident.
Residents may receive an interim evaluation after two weeks to ensure appropriate measures are taken
to correct major weaknesses. .
Call schedules
The ICU call schedule is generally finalized one month in advance. This is necessary because of the use
for bedside physicians in the ICU and the need to schedule them well in advance.
If you have any specific requests for time off, these must be made no later than three months in advance
of your rotation. They should be forwarded to the RGH ICU Administration Offices (943-3788).
Time off requests will be weighed on an individual basis taking into account the need to ensure patient
safety and proper function of the unit. Requests for time off during the first week of the rotation will only
be granted a highly selective basis, as all ICU orientation activities take place during that week.

We respect the 24-hour on-call rule and you will be relieved of clinical decision-making responsibilities at
0800h of your post-call day. However, you will still be expected to attend teaching sessions and complete
your non-clinical responsibilities.
IDEAS to help the intensive care unit to run smoothly (or, how to survive an intensive care
rotation)
1. Please enter all orders, including emergent orders, in SCM.
2. Please enter orders for initial and subsequent ventilator settings. Specific orders are
required for weaning.
3. When ordering antibiotics or other drugs used for a limited duration, please, specify the
duration of therapy or a stop date in the initial orders. Include, when appropriate, orders
for sedation breaks.
4. Plan ahead. Order x-rays and the laboratory investigations that will be required for the
following day, on evening rounds. Order drug levels, when appropriate, as you order the
drug.
5. Plan ahead, when possible, one day prior to a discharge.
6. IF IN DOUBT, ASK. We know you are not equipped on arrival with the knowledge and
skills you will need for this rotation. We are here to teach and help you.
7. WE PROVIDE 24 HOUR COVERAGE