• Rotation Directors: Dr. Charles Volk
• Rotations Locations: Naval Medical Center San Diego
• Rotation Duration: Two to Three 4-week blocks during each year of Fellowship
• Trainees/month: One

Education Purpose and Rotation Description:

The Medical Intensive Care Unit (MICU) at NMCSD provides pulmonary/critical care fellows with experiences in managing a diverse group of critically ill adult male and female patients. Fellows will gain procedural and technical skills necessary for competency in Critical Care Medicine, including indications, contraindications, complications, and limitations of these procedures. They will also have the opportunity to coordinate a multidisciplinary team involving nursing, respiratory therapists, physical therapists, pharmacists, and nutritional services. The rotation will cover ethical issues related to Critical Care Medicine, including palliative care, as well as the administration of the ICU. Fellows will serve as team leaders, under the direction of an attending physician, supervising assigned residents, interns, and medical students. They will also provide consultation for patients on other services in the ICU/CCU. The attending physician will make daily rounds, cosign admission history/physical, write an admission note, cosign all DNAR orders, and supervise invasive procedures until competency is documented. Fellows are expected to actively teach critical care medicine principles to the housestaff through rounds, at the bedside, and through the ICU core lecture series.

Rotation Objectives:

1. Acquire knowledge of and gain clinical experience in the following clinical areas:
   • Understanding acute lung injuries, including those caused by radiation, inhalation, and trauma
   • Managing respiratory failure, including adult respiratory distress syndrome, acute and chronic respiratory failure in obstructive lung diseases, and neuromuscular respiratory drive disorders
   • Studying the physiology, pathophysiology, molecular biology, diagnosis, and treatment of disorders in the cardiovascular, respiratory, renal, gastrointestinal, genitourinary, neurologic, endocrine, hematologic, musculoskeletal, and immune systems, as well as infectious diseases
   • Understanding electrolyte and acid-base physiology, pathophysiology, diagnosis, and treatment
   • Analyzing electrolyte, nutritional, and endocrine effects of critical illnesses
   • Managing hematologic and coagulation disorders secondary to critical illness
   • Addressing critical obstetric and gynecologic disorders
   • Managing anaphylaxis and acute allergic reactions
   • Understanding trauma and surgical critical care
   • Studying pharmacokinetics, pharmacodynamics, and drug metabolism and excretion in critical illness
   • Managing critical cardiac and cardiothoracic surgical disorders
   • Implementing process improvement and continuous quality assurance measures in the ICU
   • Applying “bundled care” for the prevention of health-care-associated infections.
2. Acquire knowledge and proficiency in the following procedures, understanding their indications, contraindications, complications, and limitations:
   • Establishing and maintaining an open airway in nonintubated, unconscious, paralyzed patients
   • Operating pressure-cycled, volume-cycled, time-cycled, and flow-cycled mechanical ventilation
   • Using reservoir masks and continuous positive airway pressure masks for delivering supplemental oxygen, humidifiers, nebulizers, and incentive spirometry
   • Applying weaning and respiratory care techniques
   • Managing pneumothorax through needle insertion and drainage systems
   • Maintaining circulation
   • Performing arterial puncture and blood sampling
   • Inserting central venous, arterial, and pulmonary artery balloon flotation catheters
   • Performing basic and advanced cardiopulmonary resuscitation
   • Executing cardioversion
   • Conducting diagnostic and therapeutic procedures, including thoracentesis, pleural biopsy, flexible fiberoptic bronchoscopy, and related procedures
   • Performing laryngoscopic and bronchoscopic intubation
   • Calibrating and operating hemodynamic recording systems
   • Providing ventilatory support, weaning, and respiratory care techniques
   • Examining and interpreting sputum, bronchopulmonary secretions, pleural fluid/tissue, and lung tissue for infectious agents; cytology; and histopathology
   • Performing thoracostomy tube insertion and drainage
   • Administering parenteral nutrition
   • Monitoring/bioengineering
   • Utilizing, zeroing, and calibrating transducers
   • Using amplifiers and recorders
   • Performing pericardiocentesis
   • Inserting transvenous pacemakers
   • Administering dialysis, including both intermittent and continuous renal replacement therapy
   • Performing peritoneal lavage
   • Monitoring intracranial pressure
   • Competency-Based Goals and Objectives by Year of Training:
3. Acquire knowledge and the ability to interpret the following diagnostic studies and data:
   • Chest roentgenograms
   • Computed axial tomograms
   • Radionuclide scans
   • Ultrasound in the ICU, including volume assessment, pleural, and abdominal examination
   • Other radiologic procedures      
   • Cardiac output determinations by thermodilution and/or other techniques
   • Evaluation of oliguria
   • Management of massive transfusions
   • Management of hemostatic defects
   • Interpretation of antibiotic levels and sensitivities
   • Monitoring and assessment of metabolism and nutrition
   • Calculation of oxygen content, intrapulmonary shunt, and alveolar-arterial gradients
   • Pharmacokinetics
4. Develop further knowledge, skills, attitudes, and educational experience in the core competency areas of patient care, medical knowledge, practice-based learning, interpersonal and communication skills, professionalism, and systems-based practice by:
   • Leading a multidisciplinary ICU team comprising physicians at different training levels, nurses, respiratory therapists, and pharmacists
   • Communicating with families via phone, in person, and through family conferences where appropriate
   • Discussing end-of-life care issues, pain management, and advanced care directives with patients and their families when appropriate
   • Effectively communicating with consultants from other services to ensure optimal patient care
   • Participating in morbidity and mortality conferences
   • Learning the principles and indications for organ donation and sensitively presenting this option to families of potential donors
   • Requesting post-mortem examination permission from families in a sensitive and empathetic manner
   • Participating in quality improvement activities, including death reviews
   • Ensuring patient discussions are not held in public areas
   • Obtaining informed consent for all invasive procedures
   • Learning accepted criteria for brain death and explaining this concept to family members and friends
   • Utilizing Internet and computer search strategies to obtain the latest diagnostic and treatment recommendations for patients
   • Clearly communicating consultative recommendations in writing (and in person when appropriate) to requesting physicians
   • Ensuring adequate sedation/pain control for all procedures and treatments where physical or emotional stress is anticipated.
   • Keeping the attending physician informed of significant changes in patient status and recognizing potentially serious findings or trends.
   • Conducting rounds in an efficient, professional manner
   • Communicating patient orders to nurses, therapists, and other personnel in a professional manner and according to hospital guidelines
   • Supervising junior house staff physicians during all procedures until competency has been documented.
   • Learning and applying hospital and national regulations regarding patient privacy (HIPAA)
   • Learning and applying hospital and national clinical guidelines/pathways for ICU care
   • Identifying socioeconomic and language barriers to medical care
   • Keeping abreast of current literature, including active participation in journal clubs.

Competency-Based Goals and Objectives by Year of Training:

Patient Care

This includes appropriate history taking, examination, and data gathering on all patients. Patients are admitted as transfers from the medical wards and as admissions from the emergency room. The fellow will integrate this information into specific patient care plans and implement those plans. The responsible attending must place a staff note on the chart within 24 hours of admission. Under attending supervision, the fellow is primarily responsible for all patient care and consultative recommendations provided by the ICU team.

1st year fellow

• The fellow will see, examine, and evaluate all new patients, and as appropriate in all patients with a change in their clinical status. If a house staff member or student sees the patient initially, the fellow will review the case with that individual, see the patient and assist the house staff member in developing a plan.
• Strive to interpret relevant laboratory and radiology results and present the data in an organized fashion.
• Formulate basic differential diagnosis for all ICU admissions.
• The fellow must approve all admissions and discharges to the MICU. The fellow must review every new admission’s orders and review the case with the assigned house staff.
• Ensure the plan of care is implemented by discussing it with inpatient medical teams.
• Begin to acquire expertise in diagnostic bronchoscopy.
• Review selected radiology and histopathology material with staff and radiologist or pathologist, respectively.
• Develop understanding of the pathophysiology, clinical findings, diagnostic tools, and management principles of intensive care medicine
• Fulfill continuity clinic responsibilities.

2nd year fellow

All above goals and, in addition, the following:

• Accurately evaluate (with history and physical exam) all patient consults and display the ability to independently devise a diagnostic and therapeutic management plan utilizing primary literature as required and then present a cohesive plan to the attending for input and review.
• Independently perform diagnostic flexible bronchoscopy, including via endotracheal tube, (if appropriate for fellow’s endoscopic level of supervision).
• Gain experience in therapeutic bronchoscopy
• Assist in coordination of program academic conferences
• By the end of this year fellows should exhibit the ability to practice Pulmonary Medicine in a competent and independent fashion.

3rd year fellow

All above and, in addition, the following:

• Formulate extensive differential diagnosis for common and complex pulmonary complaints
• Independently perform diagnostic flexible bronchoscopy (if appropriate for fellow’s endoscopic level of supervision).
• By the end of this year fellows should exhibit the ability to practice Critical Care Medicine in a competent and independent fashion. Specific patient care objectives include but are not limited to the following:
• Management of acute traumatic brain injury, spinal cord injury, and spontaneous intracranial hemorrhage.
• Resuscitation and post-operative management of acute traumatic injury.
• Acute management of shock including appropriate use of vasoactive medications.
• Management of cardiac arrhythmias
• Recognition and management of respiratory failure, including use of mechanical ventilation and non-invasive ventilation.
• Management of the critically ill post-surgical patient, including management of post-operative complications.
• Recognition and management of acute gastrointestinal processes including GI bleeding and pancreatitis.
• Recognition and treatment of sepsis and other acute infectious processes.
• Understand principles of prevention and treatment of hospital and ventilator associated pneumonia, as well as other nosocomial infections.
• Recognition and acute management of defects in hemostasis.
• Recognition and acute management of endocrine and metabolic emergencies in the ICU.
• Recognition and management of acute drug overdoses.
• Recognition and management of acute renal failure in the critically ill patient.
• Principles of fluid and electrolyte management in the ICU.
• Recognition and management of delirium in the critically ill patient.
• Prevention and treatment of venous thromboembolism.
• Understand and implement principles of nutritional assessment and enteral and parenteral alimentation.
• Fellows are expected to demonstrate competency including indications, contraindications, interpretation, and complications of the following procedural skills:
• Maintenance of an open airway in a nonintubated patient
• Ventilation by bag-mask systems
• Tracheal intubation
• Use and weaning of mechanical ventilation
• Arterial, central venous, and pulmonary artery catheterization
• Pericardiocentesis in acute tamponade
• Cardioversion and transcutaneous pacing
• ABG and CXR Interpretation
• Fiberoptic Bronchoscopy-Diagnostic and Bronchoalveolar Lavage

Medical Knowledge:

Fellows must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences. Fellows are expected to:

1st year fellow

• Progress from a more basic internist level understanding of the diagnosis and management of pulmonary disorders to a more in-depth appreciation of subtle diagnostic and therapeutic management issues involved with various critical care illnesses.
• Using general pulmonary/critical care references and input from faculty, should be able to develop a basic diagnostic and management plan.
• Fellows should exhibit a progressive ability to develop well thought out diagnostic and therapeutic plans prior to discussion of the case with staff.
• Understand and explain the basics of evidence based medicine
• Perform patient directed learning by reading appropriate text book chapters and review articles and performing literature searches

2nd year fellow

All above goals and, in addition, the following:

• Perform patient-directed learning by conducting literature searches to locate up-to-date medical literature and applying evidence-based critiques of the literature.
• Participation in journal club through article presentation and review.

3rd year fellow

All above and, in addition, the following:

• Perform patient directed learning by critiquing up to date medical literature and applying knowledge to patient care
• Investigate new and evolving treatment methods in a scientifically rigorous manner.
• Rigorous critique of new literature during journal club.

Practice-Based Learning and Improvement

Fellows must be able to investigate and evaluate their patient care practices, appraise, and assimilate scientific evidence, and improve their patient care practices. Fellows are expected to:

1st year fellow

• Enhance patient care practices by means of critically appraising scientific evidence and relating patients’ care practices.
• Application of evidence based medicine (incorporating knowledge of study design and statistical methods) in determining the application of medical literature to individual or population based care.
• Be able to ask an answerable question
• Understand limits of own knowledge
• Able to perform literature search

2nd year fellow

All above goals and, in addition, the following:

• Able to perform literature searches quickly and efficiently and apply knowledge to specific patient care and overall patient care practices
• Assistance with a QA/PI project in the ICU environment

3rd year fellow

The objectives outlined above apply to this level of training.

• Completion of a QA/PI project in the ICU environment

Interpersonal and Communication Skills

Fellows will communicate directly with patients, families, and professional associates. The development and maintenance of therapeutic and ethically sound relationships involving both listening and communication (verbal and non-verbal) will be stressed.

1st year fellow

• The MICU Fellow may receive calls from referring physicians at NMCSD and outlying facilities. Referring physicians must be treated with courtesy and respect.
• The fellow is responsible for ensuring a collaborative relationship with the MICU nursing staff, the pharmacy staff, and respiratory therapy.
• Demonstrate understanding of psychosocial aspects of critical care, including sensitivity and responsiveness to patients’ culture, age, gender, and disabilities
• Demonstrate an understanding of ethical and legal aspects of critical care including issues pertaining to withholding or withdrawing clinical care and informed consent.
• Adhere to all patient confidentiality policies of the Naval Medical Center.
• Demonstrate compassion, integrity, and accountability in all aspects of patient care.
• Document an initial admission note, follow up notes, telephone consults, and other procedural notes that are complete, accurate, and has plan of care clearly outlined.
• Fellows are not required to write progress notes but should enter notes as indicated when there is a significant change in a patient’s status.
• Present data to the attending staff in a clear, organized format with the ability to focus on the important or the critical issues
• Engage in teaching with medical students or residents rotating on the service.

2nd year fellow

All above goals and, in addition, the following:

• Able to negotiate with other consultative services when there are differences of opinion.
• Able to present cases to staff quickly and efficiently while communicating important information with an emphasis on assessment and plan.

3rd year fellow

All above and, in addition, the following:

• Able to lead rounds to demonstrate time management, control of presentation and discussion, and ability to prioritize.

Professionalism

Fellows must demonstrate a commitment to carrying out professional responsibilities. Patient care and interaction will be carried out in a respectful, compassionate, and ethical manner and demonstrate a responsiveness to the needs of patients and families. This will include responsiveness to patients’ culture, age, gender, and disabilities. The objectives outlined below apply all levels of training.

• The fellow will demonstrate a commitment to ethical principles pertaining to the provision or withholding of care, confidentiality of patient information, and informed consent.
• Patient care and interaction will be carried out in a respectful, compassionate, and ethical manner and demonstrate a responsiveness to the needs of patients and families to include responsiveness to patients’ culture, age, gender, and disabilities.
• Fellows must demonstrate a commitment to carrying out professional responsibilities.
• Display appropriate appearance (duty uniform) and military bearing.
• Fellows will report for all duties and makes appropriate arrangements for coverage if the need arises.
• Interactions with all members of the health care team are respectful and ethical with patient care as the primary concern.

Systems-Based Practice

Fellows must 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. Fellows are expected to:

1st year fellow

• Fellows will demonstrate an understanding and awareness of patient care in the context of the military health care system.
• Understand and apply critical care unit admission and discharge criteria.
• Understand principles of ICU bed utilization and patient flow throughout the hospital.
• The fellow will be able to discuss how patient care and professional practices affect other health care professionals and the constraints of the military medical system.
• When necessary, fellows will facilitate and coordinate patient care to other facilities within the military medical system or in the civilian community.
• Able to navigate multiple clinical data systems.
• Understand the limitations of referring facilities to determine hospital specific needs of patients.
• Able to work with the pharmacy to obtain special order medications
• Able to work with critical care support staff and head nurse to facilitate scheduling of procedures and admissions to the unit.  Identify sources of medical errors and method of reporting those errors.

2nd year fellow

All above goals and, in addition, the following:

• Understand and apply principles of cost effective medicine in the critical care environment.
• Demonstrate un understanding of the importance of protocol-directed care in the ICU environment, to include knowledge of care protocols for common conditions/situations (for example therapeutic hypothermia, ventilator weaning, enteral nutrition)

3rd year fellow

All above goals and, in addition, the following:

• Demonstrate an understanding of the importance of metrics in the ICU environment, and their role in monitoring the delivery of care (to include descriptive information, resource utilization information, and quality of care data). 
• Demonstrate an understanding of the importance of antibiotic stewardship in the ICU environment.

Learning Venues and Teaching Methods:

Direct Patient Care:

• Medical Intensive Care Units, 4th Floor Naval Medical Center San Diego
• Surgical Intensive Care Unit 4th Floor
• Emergency Room 1st Floor main hospital
• Cardiology Care Unit 4th floor
• In-patient wards 5th floor
• Operating Room, 4th floor.

Suggested Reading:

1. Textbook of Critical Care.  Edited by Shoemaker, Ayres, Grenvik, and Holbrook, W.B. Saunders, and Company.
2. Critical Care.  Edited by Civita Taylor, and Kirby, Lippincott, and Raven
3. Intensive Care Medicine. Edited by Rippe, Taylor, Alpert, and Fink. Little Brown.
4. Textbook of Respiratory Medicine.  Edited by Murray and Nadel.  W.B. Saunders and Company.
5. Fellows reading list (and literature folder) on the ICU Website Homepage.

Evaluation:

The trainee will receive a written evaluation at the end of their rotation based on cognitive, patient management, procedural, 360 degree feedback and humanistic skills.  This evaluation, including areas for improvement, will be discussed personally with the trainee at the end of the rotation and then forwarded for review by the Program Director and Education Committee for inclusion in the trainee’s permanent file.