- Rotation Directors: Carrie Chun, MD, M.D.
- Rotations Locations: Scripps Cardiovascular Institute/Scripps Green, La Jolla, CA
- Rotation Duration: One 4-week block, Split between Green and Prebys
- Trainees/month: One
Rotation Description:
The medical Intensive Care Unit at Scripps Prebys/Green provides pulmonary/critical care fellows with experience in (1) Management of a diverse group of critically ill adult male and female patients with an emphasis on perioperative patients and patients with advanced liver disease; (2) Procedural and technical skills necessary for competency in Critical Care Medicine, including indications, contraindications, complications and limitations of these procedures; (3) Coordinating a multidisciplinary team involving nursing, respiratory therapists, physical therapists pharmacists, and nutritional services; (4) Ethical issues related to Critical Care Medicine, including palliative care and (5) Administration of the ICU. As team leader, under the direction of an attending physician, the fellow supervises assigned residents. The fellow is responsible for conducting comprehensive yet efficient rounds, examining, and writing an admission note on each new patient, and supervising resident procedures until competency has been documented. The pulmonary/critical care fellow also provides consultation, upon request, for patients on other services. The pulmonary/critical care attending will make daily rounds, cosign the admission history/physical, write an admission note, cosign all DNR orders, and supervise all invasive procedures until competency has been documented.
Rotation Objectives:
- Acquire knowledge of and gain clinical experience in the following clinical areas:
- Acute lung injury, including radiation, inhalation, and trauma
- Respiratory failure, including the adult respiratory distress syndrome, acute and chronic respiratory failure in obstructive lung diseases, and neuromuscular respiratory drive disorders
- Physiology, pathophysiology molecular biology, diagnosis, and therapy of disorders of the cardiovascular, respiratory, renal, gastrointestinal, genitourinary, neurologic, endocrine, hematologic, musculoskeletal, and immune systems as well as of infectious diseases
- Electrolyte and acid-base physiology, pathophysiology, diagnosis, and therapy
- Electrolyte, nutritional, and endocrine effects of critical illnesses
- Hematologic and coagulation disorders secondary to critical illness
- Critical obstetric and gynecologic disorders
- Management of anaphylaxis and acute allergic reactions
- Trauma
- Pharmacokinetics, pharmacodyanmics, and drug metabolism and excretion in critical illness
- Acquire knowledge (indications, contraindications, complications, and limitations) of and competence in performing the following procedures:
- Establishment and maintenance of open airway in nonintubated, unconscious, paralyzed patients
- Pressure-cycled, volume cycled, time-cycled and flow-cycled mechanical ventilation
- Use of reservoir masks and continuous positive airway pressure masks for delivery of supplemental oxygen, humidifiers, nebulizers, and incentive spirometry
- Weaning and respiratory care techniques
- Management of pneumothorax (needle insertion and drainage systems)
- Maintenance of circulation
- Arterial puncture and blood sampling
- Insertion of central venous, arterial, and pulmonary artery balloon flotation catheters
- Basic and advanced cardiopulmonary resuscitation
- Cardioversion
- Diagnostic and therapeutic procedures, including thoracentesis, pleural biopsy, flexible fiberoptic bronchoscopy, and related procedures
- Laryngoscopic and bronchoscoic intubation
- Calibration and operation of hemodynamic recording systems
- Ventilatory support, weaning, and respiratory care techniques
- Examination and interpretation of sputum, bronchopulmonary secretions, pleural fluid/tissue, and lung tissue for infectious agents; cytology; and histopathology
- Thoracostomy tube insertion and drainage
- Parenteral nutrition
- Monitoring/bioengineering
- utilization, zeroing, and calibration of transducers
- use of amplifiers and recorders
- Pericardiocentesis
- Transvenous pacemaker insertion
- Peritoneal dialysis
- Peritoneal lavage
- Intracranial pressure monitoring
- Extracorporeal Membrane Oxygenation (ECMO)
- MEDICAL INTENSIVE CARE UNIT SCRIPPS GREEN/PREBYS
- Rotation Directors: Carrie Chun, MD, M.D.
- Rotations Locations: Scripps Cardiovascular Institute/Scripps Green, La Jolla, CA
- Rotation Duration: One 4-week block, Split between Green and Prebys
- Trainees/month: One
- Rotation Description:
- The medical Intensive Care Unit at Scripps Prebys/Green provides pulmonary/critical care fellows with experience in (1) Management of a diverse group of critically ill adult male and female patients with an emphasis on perioperative patients and patients with advanced liver disease; (2) Procedural and technical skills necessary for competency in Critical Care Medicine, including indications, contraindications, complications and limitations of these procedures; (3) Coordinating a multidisciplinary team involving nursing, respiratory therapists, physical therapists pharmacists, and nutritional services; (4) Ethical issues related to Critical Care Medicine, including palliative care and (5) Administration of the ICU. As team leader, under the direction of an attending physician, the fellow supervises assigned residents. The fellow is responsible for conducting comprehensive yet efficient rounds, examining, and writing an admission note on each new patient, and supervising resident procedures until competency has been documented. The pulmonary/critical care fellow also provides consultation, upon request, for patients on other services. The pulmonary/critical care attending will make daily rounds, cosign the admission history/physical, write an admission note, cosign all DNR orders, and supervise all invasive procedures until competency has been documented.
- Rotation Objectives:
- Acquire knowledge of and gain clinical experience in the following clinical areas:
- Acute lung injury, including radiation, inhalation, and trauma
- Respiratory failure, including the adult respiratory distress syndrome, acute and chronic respiratory failure in obstructive lung diseases, and neuromuscular respiratory drive disorders
- Physiology, pathophysiology molecular biology, diagnosis, and therapy of disorders of the cardiovascular, respiratory, renal, gastrointestinal, genitourinary, neurologic, endocrine, hematologic, musculoskeletal, and immune systems as well as of infectious diseases
- Electrolyte and acid-base physiology, pathophysiology, diagnosis, and therapy
- Electrolyte, nutritional, and endocrine effects of critical illnesses
- Hematologic and coagulation disorders secondary to critical illness
- Critical obstetric and gynecologic disorders
- Management of anaphylaxis and acute allergic reactions
- Trauma
- Pharmacokinetics, pharmacodyanmics, and drug metabolism and excretion in critical illness
- Acquire knowledge (indications, contraindications, complications, and limitations) of and competence in performing the following procedures:
- Establishment and maintenance of open airway in nonintubated, unconscious, paralyzed patients
- Pressure-cycled, volume cycled, time-cycled and flow-cycled mechanical ventilation
- Use of reservoir masks and continuous positive airway pressure masks for delivery of supplemental oxygen, humidifiers, nebulizers, and incentive spirometry
- Weaning and respiratory care techniques
- Management of pneumothorax (needle insertion and drainage systems)
- Maintenance of circulation
- Arterial puncture and blood sampling
- Insertion of central venous, arterial, and pulmonary artery balloon flotation catheters
- Basic and advanced cardiopulmonary resuscitation
- Cardioversion
- Diagnostic and therapeutic procedures, including thoracentesis, pleural biopsy, flexible fiberoptic bronchoscopy, and related procedures
- Laryngoscopic and bronchoscoic intubation
- Calibration and operation of hemodynamic recording systems
- Ventilatory support, weaning, and respiratory care techniques
- Examination and interpretation of sputum, bronchopulmonary secretions, pleural fluid/tissue, and lung tissue for infectious agents; cytology; and histopathology
- Thoracostomy tube insertion and drainage
- Parenteral nutrition
- Monitoring/bioengineering
- utilization, zeroing, and calibration of transducers
- use of amplifiers and recorders
- Pericardiocentesis
- Transvenous pacemaker insertion
- Peritoneal dialysis
- Peritoneal lavage
- Intracranial pressure monitoring
- Extracorporeal Membrane Oxygenation (ECMO)
- Acquire knowledge of and ability to interpret the following diagnostic studies and data pertaining to:
- Chest roentgenograms
- Computed axial tomograms
- Radionuclide scans
- Pulmonary angiograms
- Other radiologic procedures
- Cardiac output determinations by the 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
- Gain additional 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 doing the following:
- Leading a multidisciplinary ICU team that includes physicians of different training levels, nurses, respiratory therapists, and pharmacists
- Communicating with families by phone, in person, and through family conferences when appropriate
- Discussing end of life care issues, pain management, and advanced care directives with patients and their families when appropriate
- Communicating effectively with consultants from other services to ensure the optimal care of patients for whom the fellow is responsible
- Participating in morbidity and mortality conferences
- Learning the principles and indications for organ donation and presenting this option to families of potential donors in a sensitive and empathetic manner
- Requesting post-mortem examination permission from families in a sensitive and empathetic manner
- Participating in quality improvement activities including death reviews
- Avoiding discussion of patients in public area
- Obtaining informed consent for all invasive procedures
- Learning accepted criteria for brain death and how to explain this concept to family members and friends
- Utilizing the 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 housestaff 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
- Looking for and identifying socioeconomic and language barriers to medical care
- Learning Venues and Teaching Methods:
- Direct Patient Care:
- Intensive Care Units, Scripps Green Hospital, La Jolla, CA
- Cardiac Care Units, Scripps Prebys Cardiovascular Center, La Jolla, CA
- Pulmonary Clinic NMCSD
- Suggested Reading:
- Textbook of Critical Care. Edited by Shoemaker, Ayres, Grenvik, and Holbrook, W.B. Saunders, and Company.
- Critical Care. Edited by Civita Taylor, and Kirby, Lippincott, and Raven
- Intensive Care Medicine. Edited by Rippe, Taylor, Alpert, and Fink. Little Brown.
- Textbook of Respiratory Medicine. Edited by Murray and Nadel. W.B. Saunders and Company.
- Pulmonary Artery Catheter Education Project.http://www.pacep.org/
- Evaluation:
- The trainee will receive a written evaluation at the end of their rotation based on cognitive, patient management, procedural 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 to the Education Committee for inclusion in the trainee’s permanent file.
Learning Venues and Teaching Methods:
Direct Patient Care:
- Intensive Care Units, Scripps Green Hospital, La Jolla, CA
- Cardiac Care Units, Scripps Prebys Cardiovascular Center, La Jolla, CA
- Pulmonary Clinic NMCSD
Suggested Reading:
- Textbook of Critical Care. Edited by Shoemaker, Ayres, Grenvik, and Holbrook, W.B. Saunders, and Company.
- Critical Care. Edited by Civita Taylor, and Kirby, Lippincott, and Raven
- Intensive Care Medicine. Edited by Rippe, Taylor, Alpert, and Fink. Little Brown.
- Textbook of Respiratory Medicine. Edited by Murray and Nadel. W.B. Saunders and Company.
- Pulmonary Artery Catheter Education Project.http://www.pacep.org/
Evaluation:
The trainee will receive a written evaluation at the end of their rotation based on cognitive, patient management, procedural 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 to the Education Committee for inclusion in the trainee’s permanent file.