The 2 month rotation in the ICU is intended to provide residents in Internal Medicine, Surgery, Anesthesiology, Emergency Medicine, and Family Medicine with experience in the evaluation and initial management of critically ill patients. We encourage you to identify specific learning objectives for yourself, and bring them to our attention.
A two-month rotation is not going to make you an expert in the management of critical illness. However, we expect that this rotation should familiarize you with many of the various critical illness presentations, and help you develop approaches to the initial stabilization of a critically ill patient, as well as an understanding of the ICU/hospital course for patients with many of these critical illnesses.
At a minimum, we expect you to consistently demonstrate your knowledge and skills in order to:
- Recognize the patient in respiratory failure, generate a patient-specific differential diagnosis for why they are in respiratory failure, and to know the indications for initiating ventilatory support (NIV or mechanical ventilation).
- Recognize the patient in shock, generate a patient-specific differential diagnosis for why they are in shock, and to know the indications/contraindications for the use of various resuscitation fluids (including blood products), vasopressors, and inotropes, as well as the insertion and use of central venous catheters for both drug administration and hemodynamic monitoring.
- Effectively lead team resuscitation efforts for a patient in cardiac arrest, following ACLS protocols.
- Formulate comprehensive daily management plans for patients managed in the ICU, based on your own physical examination of the patients, consultation with allied health professionals, discussion with senior trainees and attending staff, and the results of various ancillary investigations.
- Communicate professionally, articulately and compassionately to colleagues, patients and their families.
As you progress through the rotation, depending on the patients in the ICU and the learning opportunities that are presented day-to-day, you will be expected to:
- Recognize the patient in shock or with significant cardio-pulmonary compromise.
- Demonstrate the appropriate use of clinical information: history, physical examination, basic laboratory and radiographic investigations to develop a reasonable differential diagnosis and management plan for such a patient.
- List the indications and contra-indications for invasive hemodynamic monitoring.
- Provide central venous access from the internal jugular, subclavian and femoral veins, and arterial access from the radial and femoral arteries.
- Use a PA catheter to obtain cardiac output, intracardiac pressures, and venous oxygen content analysis.
- Demonstrate the use of this information to modify hemodynamic function and treat shock states using: fluids (crystalloid, colloid, blood products) and vasoactive drugs including: dopamine, dobutamine, nitroglycerine, nitroprusside, noradrenaline.
- Demonstrate the appropriate use of common antiarrythmics.
- List the indications for pacemaker support. Identify patients requiring pacemaker support and for such patients, choose and initiate the appropriate pacemaker therapy (AAI, VVI and AV sequential pacing).
- Identify the patient with respiratory failure.
- Demonstrate the appropriate use of clinical information: history, physical, radiographic and laboratory to develop a reasonable differential diagnosis and initial management plan for such a patient.
- Use and recommend oxygen delivery devices appropriately (nasal prongs, low and high-flow masks).
- Provide effective bag-mask ventilation.
- Describe and identify the indications for intubation and mechanical ventilation.
- Describe and contrast basic modes of ventilation (intermittent ventilation, assist control ventilation, PEEP), and select ventilator settings (rate, tidal volume, FiO2, PEEP) appropriate for specific patients.
- Evaluate a patient's potential for weaning following short term (< 3 days) ventilation.
- Demonstrate correct placement of a chest tube and evaluate its function using a closed drainage system.
- Utilize radiographs to identify the correct placement of a venous and PA catheter, chest tube, pacer wire, feeding tube and endotracheal tube. Recognize major aberrations in chest radiographs including pneumothorax, lobar collapse, consolidation or pleural effusion, and have a practical differential of common radiographic abnormalities.
- Demonstrate the management of patients following major vascular, abdominal and cardiac surgery according to the guidelines provided in the ICU Housestaff Manual and in discussion with the surgical services.
- Demonstrate the evaluation of a patient with reduced level of consciousness, list a differential diagnosis of coma and outline a plan to investigate it.
- Describe the principles of monitoring and manipulation of intracranial pressure including the use of hyperventilation, mannitol, fluid therapy, sedation. Given a patient suspected of increased intracranial pressure, demonstrate the application of this knowledge to the patient's care.
- List the criteria for the diagnosis of brain death.
- Demonstrate the evaluation of a post-trauma patient according to the guidelines laid out by ATLS.
- Demonstrate cardiopulmonary resuscitation according to the principles outlined in ACLS.
- Identify and differentiate common coagulopathies including those due to factor deficiency, liver disease, platelet deficit or dysfunction, DIC, fibrinolysis, and consequences of massive transfusion.
- Use blood products, protamine and vitamin K appropriately.
- List the common sites and organisms responsible for infections in critically ill patients. Identify and investigate patients with suspected sepsis and select appropriate initial antibiotic therapy.
- Describe the nutritional needs of critically ill patients, recommend and monitor appropriate nutritional support.
- Correctly place and monitor venous access for TPN and feeding tubes for enteral feeds.
- Describe the basic pharmacology of common sedatives, analgesics and neuromuscular blocking agents. Select and monitor the use of these drugs appropriately.
- Describe the normal distribution of fluids and electrolytes. Demonstrate an appropriate choice of fluid therapy for patients with shock, cardiac or renal failure, and following major surgery.
- Identify the patient with significant renal dysfunction. Monitor and manage anticipated disturbances of fluids and electrolytes, including identifying the need for urgent dialysis.
- Identify anticipate and demonstrate the appropriate management of common electrolyte disturbances.
- Identify a patient with a significant acid-base disturbance, and describe a reasonable differential diagnosis and management plan.
- Identify patients with significant intoxications (due to sedative/hypnotics, TCA, ASA, carbon monoxide). Outline the supportive and specific therapies for each.
- Plan the transport of a critically ill person and demonstrate this ability in arranging the transport of such a patient to or from this centre.
- Discuss the factors determining the prognosis of critically ill patients. Demonstrate this knowledge in arriving at and discussing patient care decisions with fellow care-givers and family members.
- Describe the condition of a critically ill patient to his/her family and address their concerns in a compassionate and therapeutic manner.
- Demonstrate interacting with other physicians and health care workers in a collaborative way to arrive at a plan for patient care.
- Demonstrate knowledge of ethical principles in decision making.
- Accurately communicate your diagnostic and therapeutic plans verbally and in writing in the medical record.
- Identify your own strengths and limitations, and appropriately seek guidance and consultation.