SHANDS SURGICAL INTENSIVE CARE UNIT (SICU)

Rotation: SHANDS SURGICAL INTENSIVE CARE UNIT (SICU)

Updated: November 2012

Approved by Fellowship Program Education Committee

Fellow Level: F3                Duration: 1 month blocks

Location:          Shands SICU

Evaluation:      Done by supervising faculty in both written and verbal form

General Description:

The Shands SICU rotation includes the workup, evaluation, and management of critically ill patients following surgery and trauma. Patients seen during this rotation have a wide variety of common and uncommon surgical critical care disorders involving one or more organ systems. Patients may be admitted from the surrounding community or transferred from another institution for tertiary level care.  In this rotation the fellow has in-depth exposure to taking care of patients with critical illness due to surgical processes and trauma.  The fellow on this service is responsible for initiating and coordinating the evaluation and management of patients on the service.  The fellow is responsible for performing intubations, bronchoscopies, and chest tube thoracostomies and to assist the residents with central venous access procedures and arterial line placements.  The fellow is responsible for coordinating consultations in the SICU and interacting with consulting services in implementation of evaluation and treatment recommendations.  Fellows will provide care for patients from the Departments of Surgery and its divisions, Acute Care and Trauma Surgery, Orthopedics, Urology, and Gynecology with the anesthesia critical care medicine team.  Professionalism and helpfulness to the requested providers are expected at all times. The fellow is expected to be available to families to discuss treatment plans, response to therapy, and prognosis.  An attending anesthesia critical care medicine faculty member rounds with the fellow and SICU team to provide guidance and education as well as supervise procedures.  Faculty members from the aforementioned surgical specialties interact with the anesthesia critical medicine care team in providing guidance and education related to patient care.

Multidisciplinary management of the critically ill patient is required as part of good clinical care and is an embedded component of this rotation. The fellow will interact with and coordinate care with anesthesia critical care medicine, the various surgical specialties and subspecialties, nursing, respiratory therapy, pharmacy, social work, nutrition, and physical therapy.  The fellow will also supervise and teach residents and medical students on the rotation.

Learning takes place during bedside rounds, didactic conferences, sit down teaching rounds related to the care of patients, and through self study.

Core Competencies:

1. Patient Care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health

To recognize the following:

  • The appropriate diagnostic studies including selection, implementation, and application in the critically ill surgical and trauma patient
  • The synthesis of complex clinical information
  • The development of patient care plans in the critically ill surgical and trauma patient
  • The ability to manage single and multiorgan failure
  • The technical expertise in performing procedures necessary to practice critical care medicine
  • The ability to initiate and interpret physiologic data monitoring in the critically ill surgical and trauma patient
  • The appropriate and sensitive counseling of patient and family
  • The appropriate end-of-life decision making and ability to discuss these issues with patients and families

2. Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care

To understand the following:

  • Healthcare team-Functioning as a member of a multidisciplinary team         
  • Ethics-Understand the principles of advance directives, terminal care, withdrawal of life support and conflict resolution
  • Severity of Illness
    • Understand the rationale, applications, and limitations of severity of illness evaluation
    • Know the basic components of the common severity of illness scoring systems, such as the APACHE system
  • Hemodynamic monitoring
    • Know the indications, contraindications, techniques, and potential complications of central venous catheterization
    • Know the indications, contraindications, techniques, and potential complications for arterial catheterization
    • Know the indications, contraindications, techniques, and potential complications for pulmonary artery catheterization
    • Interpret hemodynamic data including waveform analysis
    • Know how to calculate cardiac output, SVR, PVR
    • Know the pitfalls of hemodynamic monitoring
  • Pharmacology in the ICU
    • Understand the basic principles of pharmacokinetics and how organ dysfunction and critical illness can affect drug levels
    • Understand the indications and use of sedatives, hypnotics and paralytic drugs
  • Advanced cardiac life support
  • Endotracheal intubation, artificial airways, and airway management
    • Know the indications, contraindications, techniques, and potential complications of oral and nasotracheal intubation
    • Be familiar with the indications, contraindications, care, and potential complications of tracheostomy
    • Know the principles of airway management and emergency alternatives to endotracheal intubation
  • Mechanical Ventilation
    • Understand the principles of positive pressure ventilation
    • Know the common ventilator modes, settings, alarms, and monitors
    • Know the principles and rationale for modes of mechanical ventilation for ARDS/ALI
    • Know the mechanisms, risk factors, recognition, and management of pneumothorax and barotrauma
    • Understand the principles of weaning from mechanical ventilation
    • Appreciate the indications, contraindications, techniques, and potential complications of noninvasive mechanical ventilation
  • Arterial blood gas and pulse oximetry interpretation and acid / base disturbances
    • Understand how blood gases are measured
    • Understand pulse oximetry and its limitations
    • Know the principles of acid-base physiology and acid base disturbances
    • Interpret arterial blood gases and other laboratory measurements for acid base disturbances
  • Respiratory failure
    • Understand the causes, pathophysiology, and management of various forms of respiratory failure, including hypercapnic and hypoxemic respiratory failure
  • Acute respiratory distress syndrome
    • Understand the defining characteristics, causes, and pathophysiology of ARDS
    • Know the management principles for ARDS
  • Pneumonia in the ICU
    • Understand the pathophysiology, manifestations, prevention, diagnosis and management of ventilator-associated pneumonia
  • Shock
    • Understand the various mechanisms of shock including hypovolemic, septic, cardiogenic, anaphylactic and obstructive
    • Know the principles of resuscitation from shock and understand how to monitor the effectiveness of resuscitation    
    • Know the characteristics and indications for common inotropic and vasopressor agents
  • Cardiac arrhythmias
    • Identify atrial and ventricular tachyarrhythmias, heart blocks, and EKG abnormalities associated with electrolyte disturbances          
    • Know the anti-arrhythmic agents, including indications, contraindications, potential adverse effects
  • Acute renal failure
    • Know the differential diagnosis for acute renal failure
    • Know the management principles for acute renal failure, including indications for hemodialysis and CVVHD
  • Fluid and electrolyte disorders
    • Understand the pathophysiology, manifestations, and management of the electrolyte disorders
    • Understand the advantages and disadvantages of various forms of fluid administration (crystalloids / colloids)
  • Nutrition
    • Know the principles of enteral nutrition
    • Know the principles of parenteral nutrition
    • Calculation of caloric need
  • Gastrointestinal disorders
    • Differential diagnosis, evaluation and management of upper GI bleeding
    • Differential diagnosis, evaluation and management of lower GI bleeding
    • Evaluation and management of acute pancreatitis
    • Evaluation and management of fulminate hepatic failure
    • Know the complications of cirrhosis and management
  • Hematology / Oncology disorders
    • Know the causes and management of bleeding disorders, including use of blood products
  • Nervous system disorders
    • Principles of sedative and paralytic drug administration
    • Management of elevated intracranial pressure
  • Infectious diseases issues in the ICU
    • Principles of infection control and prevention of nosocomial infection
    • Appreciate the spectrum of activity and potential adverse effects of antimicrobial agents
    • Causes and evaluation of fever in the ICU patient
    • Criteria, causes, evaluation, and management of septic shock
  • Surgical critical care
    • Understand the pathophysiology of organ dysfunction in the post-surgical patient
    • Understand the management of the critically ill surgical patient
  • Trauma critical care
    • Understand the pathophysiology of organ dysfunction in the trauma patient
    • Understand the management of the critically ill trauma patient

3. Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care

To recognize the following:

  • The effective utilization of educational and evidence-based resources to seek answers to scientific and clinical questions
  • Identification of perceived deficiencies in knowledge or experience and actively seek opportunities for correction
  • Appropriate response to faculty direction and criticism and demonstrate learning from faculty/fellow interactions
  • Proficiency at using the electronic medical record and the use of electronic resources to look up medical information
  • Commitment to self-education by attending Divisional educational activities including conferences and journal clubs
  • Facilitate the learning of students, residents, and other healthcare professionals as well as colleagues

4. Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals

To recognize the following:

  • Skills needed to interact with patients and their families in a manner that demonstrates compassion, competence and professionalism
  • Education to the residents and students working with their patients
  • The importance of peer-peer relationships and methods of handing off patient care responsibilities for safety and continuity of care
  • Appropriate relationships and communication skills with the ICU staff including nurses, pharmacists, respiratory therapists, social workers, and all other support personnel
  • Effective communication with colleagues  and consultants from other specialties

5. Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population

To recognize the following:

  • The skills needed to interact with patients and their families in a manner that demonstrates compassion, competence and professionalism
  • Keeping the patient’s best interest as the primary goal and performing these duties in a professional and courteous manner when interacting with consulting services
  • Communication skills with patients and their families with attention not just to the medical aspects of care, but also to the psychological, social and spiritual dimensions as well
  • High standards of ethical / moral behavior
  • Honesty / integrity
  • Reliability / Responsibility
  • Reaction to stressful / emotional situations in an appropriate manner
  • Commitment to on-going professional development and lifelong learning
  • Attention to documentation in the medical record and communication with other treating physicians

6. Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value

To recognize the following:

  • Importance of leadership within a healthcare team
    • Provides appropriate documentation of effort for reimbursement
    • Demonstrates knowledge of and behavior consistent with strict Medicare and insurance compliance
  • Cost-effective health care that does not compromise patient care
  • Appropriate utilization of consultants and diagnostic testing information to provide effective patient care
  • Awareness of hospice and end-of-life resources available for patients and families
  • Adequate recordkeeping skills