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Critical Care Medicine

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CRITICAL CARE MEDICINE

OVERVIEW

Critical care medicine encompasses the diagnosis and treatment of a wide range of clinical problems representing the extreme of human disease. Critically ill patients require intensive care by a coordinated team, including a general internist, subspecialist physicians, and allied health professional staff. Most often, the general internist provides care in coordination with other physicians, especially those trained in critical care. However, in some settings, the general internist may be the primary provider of care and may also serve as a consultant for critically ill patients on surgical services. Therefore, the general internist must have command of a broad range of conditions common among critically ill patients and must be familiar with the technologic procedures and devices used in the intensive care setting. The care of critically ill patients raises many

complicated ethical and social issues, and the general internist must be competent in such areas as end-of-life decisions, advance directives, estimating prognosis, and counseling of patients and their families.

I. GOALS

The primary goal for all internal medicine residents is to obtain sufficient

competence in diagnosing and managing patients with critical illness in order to: 1. Provide appropriate care for patients with a variety of critical illnesses related to single or multiple body systems.

2. Perform as a consultant for physicians in other specialties and subspecialties. 3. Make appropriate referral of more complicated patients for specialty consultation. By the end of the PGY 1 year, the resident will be expected to have a basic knowledge of the listed diseases and concepts. The ability to independently manage individual cases is expected at the end of the PGY 3 year. At all times, the resident must demonstrate the prudent ability to consult his/her peers or consultants when the need arises. These abilities and skills may be obtained through ward rotation (W), Medical Intensive Care Unit (MICU), Coronary Intensive Care Unit (CICU), Emergency Department (ED), teaching conferences (C), or self-study (SS)

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A. Principles, Physiology, Pathophysiology & Basic Science (PC, MK)

Residents will be able to demonstrate knowledge of the following principles as they apply to the care of critically ill patients:

Venue for Learning PGY

Year W MICU CICU ED C SS

1. Cardiovascular physiology 1 •

2. Vasoactive and inotropic therapy 1 •

3. Oxygen therapy 1

4. Drug dosing in renal failure 1

5. Fluid and electrolyte therapy 1

6. Dialysis (hemo and peritoneal) 2,3

7. Use of alimentation (enteral and parenteral

2,3

8. Mechanical ventilation (invasive and non-invasive), including indications, modes, complication and weaning

2,3

9. Antibiotic selections and dosage schedules

1

10. Anticoagulation and fibrinolytic therapy 1

11. Blood component therapy 1

12. Plasmapheresis for acute disorders, including neurologic and hematologic diseases

2,3

13. Prophylaxis against stress ulcer bleeding 1

14. Sedation and analgesia 1

15. Prognostic indices, such as acute

physiology and chronic health evaluation, therapeutic intervention scoring system

1 •

16. Respiratory monitoring (pulse oximetry, transcutaneous PO2, PCO2 and end-tidal

CO2)

1

17. Telemetry monitoring 2,3

18. Arterial, central venous and pulmonary artery catheterization and monitoring

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B. Diagnosis and Management (PC, MK)

For each of the following, residents will demonstrate knowledge of the clinical

manifestations and causes, and provide an appropriate differential diagnosis and approach to the acute management of:

Venue for Learning

1. Cardiovascular Disorders PGY

Year W MICU CICU ED C SS

a. Shock (all forms) 1 •

b. Cardiac arrhythmias 1

c. Cardiogenic pulmonary edema 1

d. Acute cardiomyopathy 2,3

e. Hypertensive emergencies 2,3

Venue for Learning

2. Respiratory Disorders PGY

Year W MICU CICU ED C SS

a. Acute and chronic respiratory failure 1

b. Status asthmaticus 1 •

c. Smoke inhalation and airway burns 2,3

d. Upper airway obstruction, including foreign body and infection

2,3

e. Adult respiratory distress syndrome (non- cardiogenic/capillary leak pulmonary edema)

2,3

Venue for Learning

3. Renal Disorders PGY

Year W MICU CICU ED C SS

a. Fluid and electrolytes disturbances 1

b. Renal failure 1

c. Acid-base disorders 1

Venue for Learning

4. Central Nervous System Disorders PGY

Year W MICU CICU ED C SS

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Venue for Learning

5. Metabolic and Endocrine Disorders PGY

Year W MICU CICU ED C SS

a. Hypoadrenal crisis 1 •

b. Diabetes insipidus 1 •

c. Diabetic ketoacidosis 1 •

d. Thyrotoxicosis 1 •

Venue for Learning

6. Infectious Diseases PGY

Year W MICU CICU ED C SS

a. Sepsis 1

b. Hospital acquired and opportunistic infections, including acquired immunodeficiency syndrome

1

Venue for Learning

7. Hematologic Disorders PGY

Year W MICU CICU ED C SS

a. Defects in hemostasis 2,3

b. Hemolytic disorders 2,3

c. Sickle cell crisis 1

d. Thrombotic disorders 1

Venue for Learning

8. Gastrointestinal Disorders PGY

Year W MICU CICU ED C SS

a. Gastrointestinal bleeding 1

b. Hepatic failure 1

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C. Technical Skills and Procedures (PC, MK, PBL)

Residents will demonstrate knowledge of indications, contraindications, complications, limitations, and interpretations of findings; they will demonstrate proficiency in performing the following procedures:

D. Advanced Diagnostic Procedures (PC, MK, PBL)

Residents will recognize a possible need and request consultation when appropriate for the following diagnostic modalities:

E. Ethical and Legal Aspects of Critical Care (PC, MK, PBL, ICS, P)

Residents will be able to demonstrate an understanding of the ethical and legal aspects of Venue for Learning PGY

Year W MICU CICU ED C SS

1. Advanced cardiac life support 1

2. Arterial puncture for arterial blood gas 1

3. Bedside pulmonary function 1

4. Mechanical ventilation (basic) 1

5. Placement of arterial and central venous lines

1

6. Placement of nasogastric tube 1

7. Insertion of temporary pacemaker (optional)

2,3

8. Placement of endotracheal tube (optional) 2,3 9. Placement of pulmonary artery catheter

(optional)

2,3

Venue for Learning PGY

Year W MICU CICU ED C SS

1. Bronchoscopy 2,3

2. Coronary angiography 2,3

3. Echocardiography 1

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F. Attitudes and Values (PC, MK, ICS, P)

Residents will demonstrate an understanding of the impact of a diagnosis of a critical illness and its potential effect on the lifestyles of the patient and family.

III. TRAINING ROTATIONS Medical Intensive Care Unit (MICU) Maimonides Medical Center

Yitzhak Kupfer, M.D. Chanaka Seneviratne, M.D. (718) 283-8380

The purpose of the MICU rotation is to teach residents the major aspects of understanding and managing patients with critical illnesses. Physiologic, psychosocial, diagnostic, and treatment aspects of critical illness will be addressed. The goal is to optimize the educational experience for all housestaff and provide optimal patient care to critically ill patients in the MICU. The principal teaching methods for this rotation include daily bedside teaching rounds with the critical care attending and fellow, didactic lectures, radiology rounds, case-based conferences, and direct patient care supervised by critical care attending physicians and pulmonary/critical care.

Responsibilities of the residents in the MICU include: 1. Intern (PGY 1)

a. The intern generally has first line responsibility for the patients assigned to them on their ICU rotation.

b. Patient care activities of the intern are under the supervision of the resident and fellow.

c. The intern can perform procedures appropriate for his/her level of training in the ICU. All procedures will be performed under the supervision of the residents or fellow. The level of independence in performing procedures is governed by the unit, hospital, and Department of Medicine policies.

d. The interns are expected to contribute substantially on rounds. They are expected to present their patients on rounds, and contribute to the discussion of diagnosis, management, pathophysiology, and any related basic science issues. They are expected to review pertinent

Venue for Learning PGY

Year W MICU CICU ED C SS

1. Psychosocial issues related to chronic or terminal illness

1

2. Comfort issues such as pain, nausea, vomiting, shortness of breath

1

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medical literature. Guidance from the residents and fellows will generally be provided.

e. The interns will perform full H&P on all new admissions under their care. They will be responsible for collecting all database information, reviewing prior records, following laboratory information, and writing orders under supervision of the residents and fellows.

2. Resident (PGY 2/PGY 3)

a. The resident maintains a more supervisory and teaching role in the ICU but is also responsible for the patient care administered by the interns. Therefore, they must be fully aware of all of the clinical issues in their patients, and the actions of the interns.

b. The resident can perform procedures appropriate for their level of training in the MICU. All procedures will be performed under the supervision of the MICU fellow or attending. The level of

independence in performing procedures is governed by the unit, hospital, and Department of Medicine policies.

c. Residents are expected to contribute substantially on rounds,

predominantly in areas of diagnostic and therapeutic management, as well as general education. They are expected to have a major role in reviewing pertinent medical literature.

Coronary Intensive Care Unit (CICU) Maimonides Medical Center

Gerald Hollander, M.D. (718) 283-7643

In the CICU, residents participate in all aspects of acute coronary care. The residents work up new patients as they are admitted into the unit. They participate in all work rounds and attending teaching rounds. There is a good deal of emphasis on acute hemodynamic monitoring. Residents will see patients with acute myocardial infarction who receive thrombolytic therapy, balloon angioplasty and balloon counterpulsation. Residents will also learn to recognize and treat common arrhythmias that are seen in CICU. Specific responsibilities are similar to those identified above for the Medical Intensive Care Unit.

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Web-Based Resource

www.UpToDate.com, Wellesley, MA has excellent recent review articles and bibliographies and is available in the Medical Library.

Selected Articles

Please refer to the articles identified in the Cardiology and Pulmonary sections of the curriculum for related articles in Critical Care Medicine.

V. EVALUATION

Evaluations of residents are entered on-line in the New Innovations system. At the end of each ward rotation, intensive care rotation, or subspecialty consult rotation, supervising attending preceptors will submit electronic evaluation forms representing level of achievement in the standard core competencies of the ACGME and the specific competencies outlined for the rotations. Open comments and recommendations for improvement are also documented and discussed, face-to-face, with the resident at the end of the rotation. A written exam is used to assess knowledge obtained in the Medical and Coronary Intensive Care Unit rotations and each score is factored into the knowledge competency evaluation for the respective rotations.

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