I. Preamble:
The Royal Victoria Hospital Intensive Care Unit is a 24-bed unit that cares for patients with surgical, medical, and obstetric/gynecological disorders. The ICU is divided into two services (Red and Silver). Both services care for a variety of patients, although their patient profiles differ somewhat. Residents can be assigned to either service and hopefully will spend time on both services during their time at the RVH. The philosophy of Critical Care Medicine in Canada is that it is necessarily a multidisciplinary specialty, which requires input and knowledge from several base specialties in order to cover it broad database well. Residents will round with Attending Intensivists from several backgrounds including Surgery, Internal Medicine, Respirology, Cardiology, Anesthesiology, and Emergency Medicine.
The resident should gain an understanding of the integrative nature of disease in the critically ill patient and the interdisciplinary approach to the management of such patients. The underlying general principles of Critical Care Medicine will be emphasized rather than individual diseases. Over the course of their training in the Intensive Care Unit at the Royal Victoria Hospital, each resident should gain a working knowledge of applied clinical physiology and homeostasis, be able to recognize derangement of physiology and pathophysiology, and be able to treat single or multiple organ failure. The resident should become familiar with strategies to prevent such failures in the high-risk patient. The resident should also gain an appreciation for the indications for Intensive Care Unit admissions and therapy. The resident should develop a sound understanding of the basic and applied physiology, pathophysiology, and pharmacology relevant to management of the critically ill. The resident is also expected to have mastered the fundamental aspects of technical procedures commonly used in the treatment of critically ill patients.
A graded level of responsibility will be given to the resident as he or she gains more Critical Care experience and a progressively greater depth of knowledge will be expected. On completion of the rotation in intensive care medicine, the resident should have achieved proficiency in the recognition and initial management of most problems commonly encountered in the intensive care unit.
Teaching and learning will take place in groups during formal didactic sessions, twice daily bedside rounds, and trainee presentations, as well as on a individual basis throughout the day.
II. Basic and applied knowledge (Cognitive objectives):
By the end of the rotation the resident should be able to:
Airway
- Recognize acute airway compromise;
- State the indications for, and have a sound working knowledge of emergency airway devices including use of Bag-Mask-Ventilation, oropharyngeal, and nasopharyngeal airways;
- State the indications for endotracheal intubation;
- Describe several methods of endotracheal intubation including orotracheal, nasotracheal, and fiberoptic intubation;
- State the indications for emergency surgical establishment of an airway and be capable of describing the technique;
Respiratory
Given a critically ill patient, the resident must be able to determine the presence or absence of respiratory failure, provide for its emergency support, and have a plan of action to subsequently investigate and mange the problem. These actions must be based on a sound knowledge of respiratory physiology, pathology, pathophysiology, and pharmacology.
- Recognize the clinical signs and symptoms of acute respiratory failure;
- Describe the pathophysiology of hypoxemic respiratory failure, list the 6 causes of hypoxemia, and write the alveolar-arterial gas equation;
- Describe the appropriate management of hypoxemic respiratory failure;
- Describe the pathophysiology of hypercapnic respiratory failure, and list the physiologic causes of hypercapnia;
- Discuss the role of oxygen therapy in the treatment of hypercapnic respiratory failure;
- List the differential diagnosis for an exacerbation of COPD;
- Describe the appropriate management of hypercapnic respiratory failure;
- Have a basic understanding of measurements of lung mechanics and pulmonary function tests;
- Accurately interpret arterial blood gas analysis;
- Have a basic working knowledge of the principles of pulse oximetry, capnography, and co-oximetry;
- Recognize, diagnose, and perform adequate initial investigation and treatment of specific respiratory illnesses including ARDS, cardiogenic pulmonary edema, status asthmaticus, COPD, smoke inhalation, airway burns, near drowning, severe community-acquired pneumonia, nosocomial pneumonia, and aspiration pneumonia, pneumothorax, hemothorax, empyema, massive effusion, pulmonary hemorrhage and massive hemoptysis;
- Describe the principles and the application of oxygen therapy;
- Describe the principles and application of mechanical ventilation including knowledge of the various modes of mechanical ventilation, the indications and possible complications;
- Be able to write orders for initiating mechanical ventilation including the mode, tidal volume, rate, PEEP and FiO2;
- Discuss advantages and disadvantages of common modes of ventilation (CMV, A/C, SIMV, PS, PC );
- List complications of mechanical ventilation;
- Describe the possible causes and management of an acute life-threatening elevation in airway pressures while a patient is on mechanical ventilation;
- Weaning from mechanical ventilation - describe criteria for weaning and weaning techniques
- Describe 3 common weaning modes;
- List at least 4 weaning parameters and give specific values for each;
- Describe the principles and application of non-invasive ventilatory support (CPAP and BiPAP);
- Describe the pharmacology of commonly used drugs including Beta-agonists, anticholinergics, and steroids;
Cardiovascular
Given a critically ill patient presenting with chest pain, myocardial infarction, arrhythmia, pulmonary edema, hypertension, or hypotension, the resident must be able to recognize the problem, provide emergency life support, and embark upon a diagnostic and management program to correct the instability. This must be based on a sound knowledge of cardiovascular physiology, pathology, pathophysiology, and pharmacology.
- Recognize and begin initial management of all forms of shock;
- Give a differential diagnosis of shock;
- Describe the physiological determinants of cardiac output and blood pressure;
- Write the equations for oxygen delivery, oxygen uptake, and the shunt equation;
- Describe the determinants of venous return;
- Describe or draw the Frank-Starling curve;
- Devise a therapeutic approach to the patient in cardiogenic shock; considering preload, afterload, rhythm, and inotropic interventions;
- Describe the causes and management of hypovolemic shock, obstructive shock, cardiogenic shock and distributive shock;
- Describe the pharmacology of the following vasoactive drugs
- Dobutamine
- Dopamine
- Epinephrine
- Norepinephrine
- Amrinone or milrinone
- Isoproterinol
- List the function, indications, and the role of the intra-aortic balloon pump in the setting of acute myocardial infarction and cardiogenic shock;
- Discuss right ventricular dysfunction, its causes, hemodynamic patterns, and treatment;
- Be capable to recognize, and perform the initial investigation and treatment of;
- Pulmonary embolism (thromboembolic, air, fat, amniotic) and DVT
- Treatment of cardiac tamponade and other pericardial disease
- Myocardial infarction and its complications
- Acute and chronic valvular disorders
- Pulmonary edema - cardiogenic and noncardiogenic
- Pulmonary hypertension and cor pulmonale
- Aortic emergencies - dissections and ruptured aneurysms
- Acute vascular ischemia
- Hypertensive emergencies and urgencies
- Acute cardiomyopathies
- Hemodynamic monitoring;
- State the indications for central lines and Swan-Ganz catheters;
- State the complications of central line and Swan-Ganz catheter placement and maintenance;
- Recognize the various waveforms during placement of a Swan-Ganz catheter;
- Describe the thermodilution technique of cardiac output determination and possible sources of error;
- Be able to plot the PCWP on a PA balloon occlusion tracing;
- State the indications and complications of arterial lines;
- Recognize, investigate, and treat cardiac conduction disturbances and dysrhythmias;
- Supraventicular tachycardias
- Atrial fibrillation and flutter
- Ventricular dysrhythmias - PVC's, VT, VF
- Bradycardias
- State the indications, contraindications, and pharmacology of beta-blockers, calcium-channel blockers, digoxin, adenosine, procainamide, quinidine, lidocaine, propafanone, sotolol, amiodorone, atropine, adrenaline, isoproterenol;
- List the classification of antidysrhythmic drugs and give at least one example for each;
- List the relevant energy levels required for electrical cardioversion of atrial flutter, atrial fibrillation, SVT, VT;
- List 5 predisposing factors and 3 treatments for torsade de pointes;
- Management of hypertension
- Distinguish between hypertensive emergencies and urgencies;
- Know the pharmacology, indications, contraindications, and complications for nitroglycerin, nitroprusside, labetalol, nifedipine, hydralazine;
- Peri-operative management of patients undergoing cardiovascular surgery;
- Describe all ACLS algorhytms
Gastrointestinal
Given the critically ill patient with a gastrointestinal disorder, the resident must be able to critically evaluate the nature of the illness, institute immediate life-sustaining support, and embark upon a program of precise diagnosis, continuing support and, where possible, resolution of the pathophysiological entity.
- Recognize, investigate, and treat the following;
- Upper GI Bleeds including variceal bleeding
- Lower GI Bleeds
- Pancreatitis
- Acute hepatic failure or jaundice
- Portal hypertension
- Acalculous cholecystitis
- Perforated viscus
- Intraabdominal abscess
- Ischemic bowel
- Peri-operative complications including fistulas, wound infection, and evisceration
- Describe the principles of stress ulcer prophylaxis;
- Describe the appropriate investigation of possible sepsis from the abdomen including the utility of abdominal radiography, ultrasound, CT Scans, diagnostic peritoneal taps, and diagnostic laparotomies
Renal, Fluid and Electrolyte abnormalities
Given a patient with oliguria, evidence of advancing renal failure, or established renal failure, the resident must be able to recognize the problem, institute measures to preserve remaining renal function, and provide for precise diagnosis, adequate supportive measures, and primary therapy if available.
- Distinguish between pre-renal, renal, and post-renal failure by history, physical exam, laboratory tests, and investigations, including interpretation of urinary electrolytes;
- Describe the principles of drug dosage adjustment in renal failure;
- Principles of dialysis;
- List the advantages and disadvantages of hemodialysis, CAVH-D, CVVH-D, peritoneal dialysis;
- List the indications for emergent dialysis;
- Diagnosis and management of rhabdomyolysis;
- Describe the management of the following fluid and electrolyte disorders;
- hyponatremia
- hypernatremia
- hyperkalemia
- hypokalemia
- Acid-base disorders and their management
- Write the equation for calculation of the anion gap and give a differential diagnosis for both anion gap and nonanion gap acidosis
Metabolic and Endocrine
Given a critically ill patient with metabolic-endocrine, fluid or electrolyte abnormalities, the resident must be able to recognize the nature and severity of the problem, establish a differential diagnosis and, embark on a course of definitive diagnosis, continued monitoring and support.
- Recognize and initiate the acute management of;
- hypoadrenal crisis
- diabetes insipidus
- diabetic ketoacidosis
- hyperosmolar hyperglycemic non-ketotic coma
- thyroid storm and myxedema coma
Nutrition
Given a critically ill patient, the resident must be able to evaluate the present nutritional status of the patient, identify current deficiencies, ongoing losses and extra needs induced by the illness. The resident must also be able to devise a management strategy for the provision of either enteral and/or parenteral nutrition to sustain the patient throughout the period of critical illness.
Infectious diseases and sepsis
Given a patient with catastrophic septic illness, the resident must be able to recognize the probably infective nature of the condition, institute immediate life-sustaining measures, establish a differential diagnosis of probable site of origin and etiological pathogens, and embark upon a course of definitive diagnosis, continued life-support and appropriate antimicrobial and/or surgical therapy.
- Recognize and initiate the management of
- sepsis
- hospital-acquired and opportunistic infections
- Describe the principles of
- antibiotic selection and dosage schedules for the critically ill patient
- infection risks to health care workers
- Differentiate between sepsis and the systemic inflammatory response syndrome(SIRS).
- Discuss the role of cytokines in SIRS and sepsis.
- Become familiar with the unique aspects of surgical patients and surgical sepsis.
Hematological disorders
Given a critically ill patient with a thrombotic or thrombolytic disorder, bleeding, neutropenia, or anemia, the candidate must be able to recognize the problem, provide for any indicated life-sustaining support, and proceed with an orderly course of investigation, management, continued support and treatment.
- Recognize and initiate the acute management of
- defects in hemostasis with significant bleeding
- hemolytic disorders
- hematological dysplasias and their complications
- sickle cell crisis
- thrombotic disorders
- thrombocytopenia
- Describe the principles of
- anticoagulation and fibrinolytic therapy
- blood component therapy including indications and potential complications of therapy with PRBC's, FFP, Platelets, and cryoprecipitate
Central nervous system and Neuromuscular Disorders
Given a patient with CNS crisis and/or an altered level of consciousness, or with progressive life-threatening neuromuscular disorders, the resident must be able to recognize the nature of the situation, institute immediate life-sustaining measures, carry out appropriate neurological examination, derive a differential diagnosis, and continue with appropriate diagnostic and supportive measures until the problem is eventually resolved.
- Recognize and initiate the acute management of;
- coma
- acute hydrocephalus
- brain death evaluation
- persistent vegetative state
- intracranial vascular accidents (subarachnoid hemorrhage, intraventricular hemorrhage, intraparenchymal hemorrhage)
- sub-dural hematomas
- epi-dural hematomas
- status epilepticus
- intracranial infection
- intracranial hypertension
- spinal cord injury
- Recognize, investigate, and describe the pathophysiology and treatment of raised intracranial pressure.
- Discuss the Monroe-Kellie doctrine and the physiology of cerebral vascular autoregulation. State the advantages, disadvantages, and indications for hyperventilation, mannitol, hypertonic saline, hypothermia, and induced hypertension in the management of raised ICP.
Principles of transplantation
- Describe the basic principles of
- immunosuppression
- infections in the immunocompromised patient
- organ rejection
- organ donation
- Describe the initial post-operative care of a patient with an organ transplant.
Toxicology
Given a patient suffering from the effects of an acute or chronic intoxicant, the resident must be able to identify this probability, stabilize the life-threatening complication and undertake a sequential plan to support organ function, to prevent further absorption, alter distribution, if possible, and enhance elimination by natural and mechanical means.
- Describe the following "toxidromes"
- Narcotic
- Sedative -hypnotic
- Anticholinergic
- Cholinergic
- Sympathmimetic/ Withdrawal
- Salicylates
- Demonstrate rational laboratory investigation of the poisoned patient including the concepts of the anion gap and the osmolar gap;
- Describe the indications, contraindications, complications, and benefits of gastrointestinal decontaimination procedures including gastric lavage, activated charcoal, cathartics, and whole bowel irrigation;
- Describe the indications for hemodialysis in the management of poisonings;
- Describe the indications, contraindications, complications and benefits for common antidotes including N-acetylcysteine, naloxone, flumazenil, sodium bicarbonate, atropine, glucagon, calcium chloride, digibind, physostigmine, methylene blue, ethanol;
- Recognize and initiate management of drug-induced hyperthermia including neuroleptic malignant syndrome, malignant hyperthermia, and serotonin syndrome;
- Describe the indications for ICU admission with respect to the patient with a drug overdose.
Environmental Illnesses
Given a patient who has an environmentally induced illness, the resident must be able to recognize the severity of the insult, and initiate immediate steps to stabilize the patient.
- Hypothermia
- Hyperthermia
Principles of sedation, analgesia, and neuromuscular blockade
- Describe the pharmacology and appropriate use of narcotics, benzodiazepines, and neuromuscular blocking agents.
Ethical, Legal, and psychosocial issues of critical care
Demonstrate an adequate understanding of the principles of:
- Do not resuscitate orders
- Withholding and withdrawing life support
- Principles of informed consent
- Rights of patients and families
- Advanced directives
- Death and dying
- Understanding the effect of life-threatening illnesses on patients and their families
- Palliative care issues in the ICU
III. Skills
At the end of the rotation the resident should be able to:
- Have acquired the necessary skills to perform an adequate initial assessment of critically ill patients and be able to start the appropriate resuscitative therapy. This includes patients with cardiac, respiratory, gastrointestinal, renal, hematological, or neurological failure;
- Obtain an appropriate history from the patient, family, or other medical personnel;
- Perform an appropriate problem-oriented physical examination;
- Demonstrate the ability to collect and organize patient data, including history, physical examination, diagnostic tests and laboratory values. This information must be synthesized and presented in a clear, organized, and sequential manner. The resident should be able to discriminate between more important and less important information;
- Generate a concise list of the patient's medical problems, a rational approach to a differential diagnosis, and to offer an initial investigational and management plan. Identify the problems in order of priority;
- Provide accurate documentation in the progress notes of daily events, the therapeutic goals in each individual patient, and of decisions made on rounds with the attending staff. The therapeutic plan must be clearly documented. All notes should be complete, accurate, and satisfactorily organized;
- Appropriately interpret the most commonly used tests and monitoring devices. Be able to order appropriate investigations and be aware of their limitations, advantages and risks. Discriminate and prioritize important from less important information that will allow appropriate identification of patient health problems. Demonstrate appropriate and cost effective use of laboratory and radiological investigations; and must be prepared to justify each requested test.
- Correctly interpret the following: X-Ray of the Chest, arterial blood gases, hemodynamic parameters, mixed venous blood gases, and weaning parameters.
- Effectively communicate with patients and their families, and with other members of the health care team.
- Demonstrate effective work organization in such a way that priorities are established and that co-ordination occurs with other members of the team ensuring total, acute, and continuing care of patients.
- Demonstrate proficiency in the management of cardiac arrest and the acute resuscitation of the acute resuscitation of the acutely ill patient.
The critical care resident is expected to have gained proficiency in procedures commonly carried out in the intensive care unit. For the list that follows, it is assumed that the resident will have an understanding of the indications, contraindications, limitations, and complications of each technique.
- Airway management
- Maintenance of an open airway in non-intubated, unconscious patients
- Bag-mask ventilation
- Endotracheal Intubation
- Airway suction techniques
- Respiratory
- Management of pneumothorax with needle decompression and chest tube insertion
- Thoracentesis
- Cardiovascular
- Arterial puncture and cannulation
- Insertion of central venous catheters
- Pulmonary artery catheterization (Swan-Ganz catheterization)
- Cardiac output determinations by thermodilution
- Transcutaneous pacing
- Temporary pacing with epicardial leads
- Cardioversion
- Defibrillation
- Pericardiocentesis
- Central Nervous System
- Lumbar puncture
- Gastrointestinal
- Lavage for bleeding
- Placement of dobhoff feeding tubes
- Peritoneal tap
- Placement of a Blakemore-Senstaken tube for hemostasis
IV. Attitude
At the end of the rotation the resident should:
- Be aware of the importance of clear, regular communication when caring for a patient with critical illness. Be capable of communicating easily and appropriately with consulting services, other ICU team members, nurses, pharmacists, respiratory technicians and especially the patient or the patient's family.
- Be capable of working effectively with other members of the health care team in a considerate, tactful, respectful, and professional manner.
- Be capable of assuming appropriate professional responsibilities, placing the needs of the patients before the trainee's own, ensuring that the trainee or his/her replacement are at all times available the patients.
- Recognize the limits of their competence, and seek assistance when necessary.
V. Teaching resources:
- A significant proportion of teaching will be done during the twice-daily ICU patient rounds. Residents are encouraged to ask questions and participate actively in discussions during rounds.
- Daily teaching sessions (interactive lectures) will be given each morning at 08:15 am by the ICU Attending. The residents of each ICU service are responsible for one presentation per month as a group. The list of lectures will be posted each month.
- The computer in the ICU has access to the internet with several educational sites "book marked". There is also access to Peruse for literature searches. Many lectures by ICU Attending Staff have been placed on the computer in the "ICU Reference and Teaching File".
- A list of important critical care references is on the computer.
- A mannequin is available for practice of airway management and other techniques.
- Residents who wish to obtain more experience with endotracheal intubation will be given the opportunity to go to the OR at the Montreal Neurological Institute.
- The ICU pharmacists are an invaluable source of information concerning medications and drugs. There is an extensive literature file in the ICU pharmacy.
- Residents are encouraged to discuss ventilator management and weaning issues with the respiratory technicians as well as the attending or ICU fellow.
- The recommended textbook is "The ICU Book by Paul L. Marino (2nd edition). Copies of more advanced Critical Care textbooks are also available in the ICU. Many residents have also recommended "Critical Care Secrets" as a useful text for learning basic ICU principles.
VI. Evaluations:
A final written evaluation will be given and discussed with the resident at the end of the rotation. Residents will be notified during the course of the rotation if any significant problem areas are identified and given help to correct any deficiencies. Residents are encouraged to seek interim oral feedback from each attending staff at the end of each week.
These objectives will form the basis for the final evaluation. All Attending Staff, the ICU Fellow or Senior, and the Head Nurse will all be asked for their input for resident evaluation. The residents will be evaluated based on their performance on daily patient rounds and while on call. Academic performance will be assessed during the morning ICU teaching sessions. Technical skills will be evaluated at the bedside with the use of an objectively structured "procedure check sheet" by the ICU Attending, Fellow or Senior. It will be the resident's responsibility to ensure the check sheet is filled out.
A superior evaluation will be given to residents who far exceed reasonable expectations for their level of training. These residents will demonstrate a strong interest in critical care and exceptional problem solving ability. They will demonstrate imaginative, innovative, creative, independent thinking based on a strong base of knowledge. He or she will have the ability to generate relevant clinical questions at the bedside, search and critically appraise the recent medical literature for validity and usefulness, and be able to independently apply the literature to patient care.
Residents will be given borderline or unsatisfactory evaluations if it is felt that they do not possess the necessary knowledge, skills, or attitudes to safely and competently recognize, clinically assess, and stabilize critically ill patients.