General Overview and Educational Goals: The critical care fellow will complete a minimum of 5 weeks per year on the ICU 2 service, which includes the care of the cardiothoracic (CT) patient. During this rotation, the CCM fellow will care for post-operative cardiac and thoracic patients, along with advanced practioners and attendings. Common cardiac surgeries include (but are not limited to) on and off cardiopulmonary bypass CABG, valvular surgery, repair of aortic diseases (aneurysm and dissection), pericardial windows, pacemaker placement, intra-aortic balloon pump and ventricular assist devices including extracorporeal membrane devices. Upon completion of this rotation, it is expected the fellow will have exposure to and develop clinical expertise in cardiopulmonary resuscitation, central venous and pulmonary arterial catheters, management of pacemakers, computations of cardiac output and of systemic and pulmonary vascular resistance, monitoring electrocardiograms, pharmacologic and mechanical support of circulation, fluid resuscitation and management of massive blood loss in the post-op CT patient. The critical care fellow will partake in educational experience including attending style note writing and lessons on critical care billing.
Faculty and Rotation Summary:
I. List of faculty: During the CT ICU rotation, the CCM fellow will round daily with an intensivist and interact daily with the cardiac surgeons. Dr. Jacqueline Honig is the director of the CT ICU. Many of the critical care physicians that round and teach on the medical and neuro-trauma ICU will also work in the CT ICU (although on separate weeks). See the main ICU curriculum for a list of faculty.
II. Hours, Summary of a typical Day, Expectations: The ICU 2 rotation is 7 days, Monday through Sunday from 7am to 7pm. Once the fellow has adequate exposure to the care of the post-op cardiac patients and is deemed competent by the PD and CCC, the CCM fellow will also work nights on ICU 2 (6 days, 7pm-7am). Rounds with the cardiac surgeon take place at 7am with the night fellow and the cardiac surgeon. Daytime teaching rounds begin at 9:30 am with the CCM fellow, A.P.s, and the Intensivist. The roles/responsibilities of the CCM fellow is as follows:
- CCM fellow will partake in the care of post-operative cardiac patients as the primary provider, including providing post-operative resuscitation, order writing and documentation with an admission note or progress note. Experienced advanced practitioners, critical care attendings and cardiothoracic surgeons will provide one on one training in the management of the post-op cardiac patient.
- Critical Care admissions: The ICU 2 CCM fellow will be responsible for holding the admission pager and admitting patients (order writing and H and P documentation) of patients who present from the ED, PACU, and floor between the hours of 8am to 12pm during the time that the ICU 6-5 team is rounding.
- The CCM will be expected to assist in the management of the remainder of the ICU 2 patients. The CCM will be expected to write attending style notes and practice billing with the ICU 2 attending of the week.
- Nights on ICU 2- CCM will care for all patients on ICU 2. Nights – maximum of 6 nights in a row.
The intensivist on the ICU service will conduct teaching rounds. When daytime rounds have been completed by the ICU 6-5 team, the ICU 2 will sign out the admissions to their service. The ICU 2 team will also assume the care of any new ICU 2 patients during the day. During downtime, the CCM fellow is expected to read on topics listed below, participate in research or quality projects, and assist the ICU fellow on floors 5 and 6 with procedures.
Competency Based Objectives:
- Demonstrate ability to access accurate sources of information from the patient and/or family, OR record, and from the primary surgeon.
- Gather and organize the data necessary to generate a problem oriented differential diagnosis and plan of management
- Prioritize current CT- ICU patient care needs during daily care
- Demonstrate proficiency in performing the following procedures:
- central line placement (IJ, Subclavian, Femoral lines)
- pulmonary artery catheter placement
- A-line placement (radial, brachial, and femoral)
- Cardioversion, Defibrillation
- Chest Tube Insertion and Removal
- Drainage Systems
- Demonstrate proficiency in ABG and VBG interpretation
- Demonstrate proficiency in the interpretation of arrhythmias, pacemakers, pulmonary artery catheter data, invasive blood pressure monitoring, intra-aortic balloon pumps and pulse contour analysis.
- Demonstrate proficiency in the management of drainage systems and pleurodesis.
- Integrate information based on hemodynamic monitoring to determine type and amount of vasoactive and inotropic therapy.
- Integrate information based on hemodynamic monitoring to determine the volume status of a patient and the appropriate intervention.
- Display the appropriate use of anti-arrhythmics beyond standard ACLS.
- Demonstrate the ability to triage and prioritize the evaluation and management of the post-op CT patient.
- Utilize subspecialty consultation appropriately during the care of the CT patient.
- Evaluate and determine the appropriate timing to liberate a patient from the ventilator following surgery (Both the fast track patient and the complicated patient)
- Select and titrate the appropriate analgesics in the post-op CT patient.
- Provide appropriate glucose management in the post-op cardiac patient
- Demonstrate knowledge of the cardiovascular pharmacology and pathophysiology of the post-op cardiac patient.
- Demonstrate knowledge of the cardiovascular pharmacology and pathophysiology of the post-op thoracic patient.
- Seek and locate resources useful to secure medical knowledge.
- List the risks, benefits, indications and potential complications for the critical care procedures as listed in patient care.
- Describe 4 types of shock and its complications.
- Recognize cardiac arrhythmias and conduction disturbances
- Discuss vasoactive and inotropic therapy. Describe the mechanism of action and their potential side effects of each drug.
- Derive the equations of oxygen transport and utilization.
- Define pulmonary hypertension and cor pulmonale
- List the medications indicated for pulmonary hypertension
- Distinguish between cardiogenic and non-cardiogenic pulmonary edema
- Define the criteria used for weaning a post-op patient from the ventilation
- Explain the difference between the following blood therapy components and list their indications in the post-op CT ICU patient
- Red Blood Cells
- Fresh Frozen plasma
- Coagulation factor concentrates
- Define the mechanism of action, indications, contraindications, and side effects of paralytics, analgesics, and sedatives used on ICU patients
- List the indications, risks, and contraindications of performing a pericardiocentesis
- List the indications, risks, and contraindications for insertion of
- Extra-corporeal membrane oxygenation
- Ventricular assist device
- Describe the indications, risks, and contraindications for insertion of an intra-aortic balloon device.
- Appropriately identify themselves to the patient and/or family members and the primary CT surgeon.
- Present clear and concise medical reports in the clinical presentation of
CT ICU patients.
- Demonstrate skill in conducting family conferences concerning prognosis, end of life care, code status, and withdrawal of support with the assistance of the ICU and CT attending.
- Develop a good rapport with co-workers including ICU attending, CT primary surgeon, mid-level practitioners, nursing staff and respiratory therapists in order to provide safe and efficient care to the CT patient.
- Contact and Communicate effectively with a patient’s primary surgeon upon a patient’s admission, change in clinical status and upon transfer or discharge.
- Demonstrate sensitivity to different educational levels and socio- cultural backgrounds
- Provide education and counseling to patients and families, using nontechnical and clear language.
- Demonstrate punctuality and appropriate attendance to rounds
- Demonstrate the following professional attributes
- Respond positively to constructive criticism by improving behavior and/or skill
- Maintain patient confidentiality
- Demonstrate accountability and admit to error
- Provide compassion and empathy by listening attentively and responding to concerns of patients and families
- Interact with patients and staff in a respectful manner including appropriate dress, verbal and non-verbal behavior
- Indicate knowledge of one’s own limitations by seeking guidance/ supervision from attending.
- Respond positively to constructive criticism by improving behavior and/or skill
- Demonstrate commitment to on-going professional development through reading of the medical literature as demonstrated by active participation in teaching rounds and ICU conferences
- Obtain proper informed consent from patient or family member/legal guardian
System Based Practice:
- Exhibit resource allocation and demonstrate commitment to the practice of cost-effective medical care.
- Consider cost/benefit analysis of diagnostic or therapeutic interventions prior to initiation
- Effectively collaborate with the CT attending, midlevel practioner, and thoracic resident to coordinate transition from the ICU to the floor.
- Recognize the available resources available and communicate with the support staff in the ED, PACU, and the ICU.
- Appreciate the necessity and rationale for program policies, protocols and procedures (i.e. STS data)
Practice Based Learning:
- Demonstrate a willingness to learn from errors. Identify strengths, deficiencies and limits to knowledge and expertise
- Use updated information from different sources (internet, textbooks, mdconsult) to improve knowledge of pathophysiology and to improve patient care practices.
- Interact with nursing staff and other professionals as two-way educational opportunities
- Demonstrate an understanding of the principles of evidence-based medicine and statistics by performing a critical appraisal of the literature
- Procedures: Procedures and competency will be documented in medhub.
- Quarterly ICU Evaluation: The fellow’s performance in ICU 2 will be captured in the quarterly critical care fellow evaluation as well as with 360 evaluations. Specific questions regarding the care of post-operative cardiac patients and the ability to work with advanced practitioners will be addressed here.