SICU Rotation: PGY-2 Level

Surgical Intensive Care Unit (SICU) Rotation

PGY-2 Level


Introduction

Comprehensive Intensive Care Unit (ICU) management is a 24-hour a day process. Signs of physiologic deterioration in critically-ill patients must be identified and dealt with early in order to decrease the likelihood of multi-system organ failure development and subsequent death. In other words, our goal of ICU training is to teach you proactive rather than reactive practices.

ICU care is best practiced with a multidisciplinary approach. Our Surgical Critical Care team consists of a board-certified surgical intensivists, PGY-1 & - 2 general surgery residents, physician assistants (PA), and often students (PA or medical). Some years we will have a Surgical Critical Care Resident (i.e., a surgeon obtaining additional training toward board certification in surgical critical care). Non-physician members of the team include ICU nurses, respiratory therapists, pharmacists, physical therapists, nutritional support team members, and caseworkers.

It cannot be stressed strongly enough that it is vital to work constructively and amicably with all team members. Good rapport with the staff will lead to better patient care. The majority of nursing and respiratory staff is highly trained and experienced. They, by in large, possess sound judgment which should not be discounted. You will depend on them for accurate information, early warning of potential problems, execution of complex orders, and the set up and use of multiple, complex monitoring devices.

The Maricopa Medical Center (MMC) Surgical Intensive Care Unit (SICU) is a 13-bed unit located on the fourth floor of MMC. The SICU provides comprehensive critical care services for all varieties of surgical patients. The majority of patients are typically trauma, neurosurgery, and general surgery patients, but burn and surgical subspecialty patients are also cared for in the SICU.

Organization of the Service

There are four SICU Attending surgeons who provide all the daytime coverage in the SICU: Drs. Kopelman, O’Neill, Matthews, and Cox. Typically, the SICU Attending is on-service for one week at a time. Daytime coverage is from 0800 until 1700, Monday through Friday.

There are six Attending surgeons (Drs. Caruso, Foster, Kopelman, O’Neill, Matthews, and Cox) who take the majority of nighttime, weekend, and holiday call for Trauma / Emergency General Surgery. Due to their being in-house, they typically cover the SICU service after-hours. Two additional Attending surgeons, Drs. Miller and Goodman, occasionally take night-time and weekend Trauma / Emergency General Surgery call. When the latter two are on-call, there will be a board-certified surgical intensivist that rounds daily in the SICU and that is available by phone thereafter. If needed, they will come in from home to perform patient care.

All Attending Trauma / Emergency General Surgeons take in-house call 24/7. They are available weekdays from 1700 until 0800 the next morning. Weekend (Saturday and Sunday) and Holiday call is from 0800 to 0800 (24-hour shifts) and predominantly consists of Drs. Kopelman, O’Neill, Matthews, and Cox.

The service is composed typically of two junior surgery residents (PGY-2 and PGY-1). Occasionally, a mid-level provider may be on-service. Also, PA and MS-IV medical students occasionally rotate on the service. Nighttime coverage for the SICU is provided by a PGY-2 resident; this is described under the Emergency General Surgery (EGS) rotation description.

An organization chart is shown below:

Expectations

Service: SICU team will co-manage the patient in conjunction with the primary service.

The SICU team will be responsible for the detailed clinical management of the patient including sedation and analgesia, ventilator management, cardiovascular support, fluid and electrolytes, nutrition, antibiotic administration, deep venous thrombosis prophylaxis, glycemic control, etc.

In general, any clinical decisions based on the patient’s surgical issues (i.e., what surgical operation / disease that got them into the SICU in the first place), will be made by the primary team.

Division of Labor and Specific Duties: The junior surgery residents on the SICU service are responsible for the entire service. Division of labor will occur immediately after morning checkout rounds under the guidance of the Surgical Critical Care Resident (if present); otherwise, the PGY-2 resident will divide the labor equitably. All rounding and documentation should be completed by the scheduled time of Attending rounds (seeSurgical Critical Care Manual for details).

Procedures should wait until the arrival of the SICU Attending. Urgent and emergent procedures should be performed as the patients condition allows (the SICU Attending should be immediately informed). The PGY-2 resident will have the right of first refusal for all procedures in the SICU; however, it is expected that the PGY-1 resident will perform at least half of the procedures. Supervision of the procedures should be commensurate with experience. Residents are responsible for logging their procedures for residency credit.

Specific duties of the PGY-2 Surgical Intensive Care Unit Resident include, but are not limited to:

  • Attendance at the SICU portion of Morning Report
  • Assignment of morning rounding duties and pre-rounding procedures (unless a Surgical Critical Care Resident is on-service)
  • Presence in the SICU during duty hours
  • Preparation for morning rounds, including (but not limited to):
  • Gather patient information
  • Personally performing a thorough physical exam on each assigned patient
  • Write patient notes that were not completed by the EGS SICU PGY-2 resident
  • Act as a leader for the junior SICU team members to emulate
  • Presence at formal rounds with SICU Attending
  • Performance of bedside procedures under the guidance of senior SICU team members
  • Ensuring that proper written documentation occurs
  • For procedural consent per MIHS policies
  • Following each invasive procedure
  • If the patient’s status declines
  • For meaningful indications as outlined by the SICU Attending
  • Supervising bedside procedures performed by junior members of the SICU team
  • Ensuring that the culture book is updated daily
  • Participating in the weekly multidisciplinary SICU conference
  • Communicating with the primary service what the SICU plan is for their patient on a daily basis
  • Updating patients and their families appropriately (at least daily)
  • Brief bedside rounds with the SICU team in the afternoon prior to Afternoon Check-out to ensure the day’s plans have been accomplished and to prioritize the evening’s work list
  • Be an active participant in checkout rounds to the EGS PGY-2 resident
  • Presence and participation at scheduled educational conferences

Operating Experience:The SICU residents are not expected to participate in any surgeries unless there is a critical need for their presence in the operating room. Their primary responsibilities must have been fulfilled, and they must have permission from the SICU Attending to participate in surgeries. Surgeries on patients in the SICU will be the responsibility of the primary service.

Clinic: There will be no formal clinic responsibilities.

Conferences:Mandatory conferences include Basic Science, Morbidity & Mortality, and Grand Rounds on Wednesday morning from 06:00 to 09:00. In addition, there are noon conferences on Wednesdays (Trauma / Critical Care), Thursdays (Burn Care), and Fridays (Clinical Review). SICU-specific conferences include Joint SICU / Trauma Rounds on Tuesday afternoons at 14:00, Multidisciplinary SICU Conference on Thursday mornings at 08:00, and Critical Care Book Review each Friday at 13:00.

Procedures:All sterile procedures must be performed with full universal precautions and sterile technique as outlined in MIHS policies and procedures. Deviation from this will result in disciplinary action as outlined in MIHS policies.

Maricopa residents have competency requirements that must be met prior to performing procedures independently, such as central venous access, arterial lines, and tube thoracostomies. All rotating SICU residents must demonstrate proficiency at procedures to the satisfaction of the Surgical Critical Care Resident (if present), primary service Chief resident, or Attending prior to performing procedures independently. All procedures must be accompanied by a written procedure note placed in the chart immediately following the procedure. The SICU Attending must be notified prior to performance of bedside procedures. Bronchoscopy procedures performed by residents must be done so in the presence of the SICU Attending unless the Attending gives permission for the procedure to be done in their absence.

Research: We have numerous clinical and basic science research trials ongoing at any point in time. Residents will be made aware of these trials for educational purposes. Resident participation in research is strongly encouraged and vigorously supported.

Textbook: The textbook for the SICU rotation is The ICU Book by Marino.

Literature: We are actively compiling and cataloguing electronic copies of what we consider to be pivotal Surgical Critical Care publications. We expect the rotating residents to actively contribute to this endeavor for the benefit of all.

Call: The SICU team is on for the hours listed above.

Evaluation:The evaluation criteria that will be used by the Chief surgical resident, the mid-level providers, and the Attending Surgical Intensive Care Unit surgeons to evaluate you are listed below. Additionally, each evaluator is asked to submit a subjective narrative of overall impression, areas of strength and improvement, and overall performance. You will also be asked to evaluate the EGS rotation, your attending surgeons, and your chief residents.

Surgical Intensive Care Service Organization and Work Schedule

The SICU Attendings have established expectations for the resident house staff and mid-level providers while working on the SICU Service. The following document, although not all-inclusive, gives guidance on how the SICU Service should be administered. Omissions are not a license for house staff or mid-level providers to shirk responsibilities; rather, these professionals should feel free to point out such discrepancies to the Attendings so that resolution and remedy may be obtained.

A significant component of being on the SICU Service is performing service-oriented tasks for your patients. A sense of ownership and responsibility for patients remains crucial even in the face of resident work hour restrictions. If you remember the credo “Give my patients the same care I would want my family to have” and you will do very well. Cutting corners and dishonesty will be met with significant consequence.

We want the SICU Service to represent a positive experience for each resident and mid-level provider. Although this is not always possible, we will strive for this important goal.

The contact person for the Surgical residents while on the SICU Service will be the Co-Directors of the SICU, Drs. Tammy Kopelman or Patrick O’Neill. They will be available for discussions of any concerns, issues, and / or problems occurring on the SICU Service. Should neither of these Attendings be available, the resident should feel free to approach the SICU Attending of the week.

The Trauma Mid-Level Providers are an integral part of the Trauma System / Trauma Team and are key in providing a continuum of care for our patients. The Trauma Mid-Level Providers ultimately answer to the Trauma Attending Staff; however, the Trauma Chief will have direction over the Mid-Level Providers. While in the SICU, the Trauma Mid-Level Providers are present to further their education and off-load some of the patient care burden from the residents. It is expected that interactions with them will be in the spirit of “excellence in patient care” and be conducted with professionalism.

The SICU Team’s weekly schedule is as follows (all times subject to change):

Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / Sunday
06:00 / Check-outRounds / Check-outRounds /

Basic Science Lecture

/ Check-outRounds / Check-outRounds / Check-outRounds / Check-outRounds
07:00 / Morbidity & Mortality
08:00 / Grand Rounds / SICU Multi-disciplinary
09:00 /
SICU
Rounds
/
SICU
Rounds
/ Trauma Clinic / SICU
Rounds
/ SICU
Rounds / SICU
Rounds
10:00 / SICU
Rounds / SICU
Rounds
11:00
12:00 /

Trauma / Critical Care Conference

/

Burn Conference

/

Clinical Review Conference

13:00 /

(12:45)

Trauma M&M

/ Trauma Clinic /

Critical Care Review

14:00 /
Trauma / Surgical
15:00 / Critical Care Joint Rounds
16:00
17:00 / Check-out Rounds / Check-out Rounds / Check-out Rounds / Check-out Rounds / Check-out Rounds
18:00– / Check-out Rounds

Objectives

The specific objectives for this rotation and this level of training are listed below.

PATIENT CARE

  • Communicates effectively and demonstrates caring and respectful behaviors when interacting with patients and their families
  • Gathers essential and accurate information about his/her patients
  • Makes informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment
  • Develops and carry out patient management plans
  • Counsels and educates patients and their families
  • Uses information technology to support patient care decisions and patient education
  • Provides health care services aimed at preventing health problems or maintaining health
  • Works with health care professionals, including those from other disciplines, to provide patient-focused care
  • Manages infectious complications including: ventilator-associated pneumonia, catheter infection, urinary tract infection, skin and soft tissue infection, and intra-abdominal infection
  • Understands the pathophysiology and manage the open abdomen in patients with damage control laparotomy, abdominal compartment syndrome, and abdominal infections
  • Treats endocrine problems of the critically ill including: adrenal insufficiency, diabetes insipidus, syndrome of inappropriate ADH secretion, and serotonin syndrome

MEDICAL KNOWLEDGE

  • Demonstrates an investigatory and analytic thinking approach to clinical situations
  • Knows and applies the basic and clinically supportive sciences which are appropriate to his/her discipline
  • Uses advanced ventilator techniques including: APRV, reversed I:E ratio, high PEEP, lung-protective ventilatory strategies, and use the VDR-4, Servo-I, and 3100B ventilators
  • Recognizes the need for nutritional support and formulate caloric, protein, and other nutritional regimens
  • Understands the principles and use of continuous renal replacement therapy (CRT) in the critically ill patient

PRACTICE-BASED LEARNING AND IMPROVEMENT

  • Analyzes practice experience and perform practice-based improvement activities using a systematic methodology
  • Locates, appraises, and assimilates evidence from scientific studies related to his/her patients’ health problems
  • Obtains and uses information about his/her own population of patients and the larger population from which his/her patients are drawn
  • Applies knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness
  • Uses information technology to manage information, access on-line medical information, and support his/her own education
  • Facilitates the learning of students, residents, and other health care professionals
  • Constructs strategies to avoid development of antibiotic resistance in the SICU
  • Interprets literature in an evidence-based medicine methodology

INTERPERSONAL AND COMMUNICATION SKILLS

  • Creates and sustains a therapeutic and ethically sound relationship with patients
  • Uses effective listening skills, and elicits and provides information using effective nonverbal, explanatory, questioning, and writing skills
  • Works effectively with others as a member or leader of a health care team or other professional group
  • Communicates end of life issues effectively
  • Functions as an effective team member

PROFESSIONALISM

  • Demonstrates respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development
  • Demonstrates a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices
  • Demonstrates sensitivity and responsiveness to patients’ culture, age, gender, and disabilities
  • Involves patients and their families in care management plan and medical decision making
  • Treats patients and families with respect, compassion, and empathy
  • Dictates operative reports and discharge summaries in a timely fashion

SYSTEMS-BASED PRACTICE

  • Understands how his/her patient care and other professional practices affect other health care professionals, the health care organization, and the larger society and how these elements of the system affect his/her own practice
  • Knows how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources
  • Practices cost-effective health care and resource allocation that does not compromise quality of care
  • Advocates for quality patient care and assist patients in dealing with system complexities
  • Knows how to partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance
  • Appreciates the ethical issues involved with end or life, withdrawal of support, “do not resuscitate” orders, brain death, and organ harvest and transplantation

PROCEDURAL MASTERY