1. Welcome to the Intensive Care Unit

2. Learning Goals To learn to care for critically ill patients To understand management of respiratory failure with mechanical ventilation To develop a better appreciation of cardiopulmonary physiology To understand indications for different modalities of hemodynamic monitoring To improve on techniques to place invasive monitors

3. Learning Goals Understand the pharmacodynamics and pharmacokinetics of sedatives Learn the communication skills required in the role of the critical care consultant Develop a multidisciplinary treatment plan for critically ill patients Have a fun and educational month

4. Organization 8/11 ICU – ± intern, ± 1-2 residents, fellows, attending 9 ICU – 2 NPs, 2-3 residents, fellows, attending 10 ICU – 1 NP, 1 resident, fellows, attending 13 ICU – 4 residents, fellows, attending

5. Housekeeping - call schedule Call is approximately every 3-4 nights. A non-call resident should be identified and stay until at least 5pm rounds to help with the work. Schedule changes are not allowed unless approved by Dr. Shimabukuro (an extremely complex schedule)

6. Housekeeping - Call rooms 13 ICU - L 1351, code 911911 8/9/10 ICU - in proximal 9 ICU, no code ICU fellow - in distal room of 9ICU, no code

7. Housekeeping - daily routine Lectures start at 8am sharp everyday (except 8:15 on Wednesdays) in room M919 Check schedule for location and speaker Rounds start at 9am weekdays and at 8am on weekends X-ray rounds immediately follow attending rounds Afternoon rounds with fellows start at 5pm

8. Housekeeping - weekend Only on-call and post-call residents round Try to pre-round on the sick ICU patients Remainder of patients can be discovery rounds Please try to write notes either before or after rounds Place emphasis on A/P not repeating data

9. Housekeeping - Lectures Everybody will be responsible for 1 lecture during their rotation Please check the lecture schedule for assigned topic and date Medical students are allowed to pick a topic of their choice Read schedule carefully, sometimes lectures are split based on level of training or ICU experience

10. Housekeeping - paperwork List to be described on following slides Notes Patient list Admit Orders Procedure Note Central Line Procedure Note

11. Notes Do not repeat data that is already listed elsewhere Short and concise notes are the key For instance, “wean vent as tolerated” vs. “Patient continues to require a high minute ventilation due to a large dead space fraction. He may not tolerate a rapid wean, so will decrease the rate by 2 today.”

12. Patient list The filemaker database is in the fellow’s office. It should be updated daily Post call resident will print out copies for the team Do not leave in the ICU (patient confidentiality) Make sure to enter morbidities and mortalities

13. Admit Orders There are pre-printed ICU admit orders ICU orders are on its own page Please make sure you sign these Try to use the pre-printed orders since they are compliant with pharmacy regulations

14. Procedure Notes Located in NoteWriter Central Line Insertion Procedure Note (CLIP) CCM-Procedure Note

15. Procedure Note for Central Lines NoteWriter Central Line Insertion Procedure Note (CLIP) Attesting provider is Attending of week.

16. CCM-Procedure Note Can check more than one procedure Attesting provider is Attending of week

17. Resident Responsibilities Code Blue Coverage (10 ICU team) Emergency calls in the ICU Co-Managing patient with primary teams With special emphasis on: Airway Central lines Mechanical ventilation Pain and sedative medications

18. Code Responsibilities 10 ICU team will respond to codes during weekdays We are responsible for the airway - FIRST Please make sure that whatever you use in the CODE bags are refilled immediately New medication syringes are available from pharmacy daily (across from M919) Anesthesia workroom has other supplies – it is located in the OR on the fourth floor

19. Emergency Calls Calls regarding unstable patients often go to the ICU team If situation is truly an emergency, deal with the problem while the primary team is being summoned If there is time, discuss with the team, often the night float will be thankful for a friendly word of advice

20. Communication Understanding the primary team’s plans and goals often make it easier to understand the course of action that is planned Communication makes it easier for all parties involved and improves patient care If there is a disagreement about care, consult your fellow or attending

21. Airway The airway pager (443-4990) will always be with an anesthesiologist (attending or resident) Airway backup available: OR E1 Anesthesia Attending: 3-1581 OR Front Desk: 3-1545 OB Anesthesia Resident: 443-9261 ED: 3-1238 Do not start sedation/paralysis without someone from anesthesia being present (CA-1 residents should also always get back-up)

22. Central Lines Except for a few services we are responsible for all line placements (CT, cards, vasc) All upper body lines must be placed with an ICU attending or fellow present Femoral lines are at the discretion of the resident 3 line placements will be formally evaluated by fellows (give completed cards to Mitch in M917)

23. Ventilation We are responsible for ALL ventilator orders and extubation (except fast-track CABG – who are on a protocol) If the primary team wants something that is unreasonable, please discuss it with the fellow or attending DO NOT make changes on the ventilator Pts should be followed for at least 24 hours after extubation

24. Sedation We write pain and sedation orders on all patients we follow Do what the primary team wants if it is reasonable Management of pain in ICU patients with epidural catheters is the responsibility of the acute pain service, but we do keep a close eye on this

25. Miscellaneous Radiology does not interpret any studies overnight unless asked Small cards have everybody’s pager and home phone number Meal cards are obtainable from Mitch in the office (M917) Please don’t hesitate if you identify problems during your rotation to notify your attending Please fill out the evaluations. Your comments are confidential and important for future rotation development

26. Medical Students Stay late 1 night per week - their choice They should read about their patients Quality not quantity (2 patients max) They are not expected to function as a resident during this rotation There should be a resident identified as the supervisor for each patient the students follows

27. Calls to evaluate patient Go see the patient in the ER or on the floor Discuss ALL ICU admissions with fellow (or attending) Any refused admission must be discussed with attending or fellow Do not worry about beds, triage attending (443- 4443) will take care of that Triage covered by 10 ICU fellow

28. Open and Closed ICU’s Most patients in M/L ICU’s are “semi- open” in that primary service still writes some orders, but we co-manage with them. Orthopedic surgery, CRI, post-partum OB, ENT/ plastics and Urology are “closed” Make sure you know their contact #’s to keep them in the loop

29. Closed patient issues Labs - transfusion, electrolytes, glucose Nutrition - NPO, tube feeding, TPN Activity - bedrest, ad lib IVF - rate, heplock Studies - radiology, echo, PT - need to make a phone call Check patient frequently and communicate with primary team often

30. Open and Closed ICU’s The data: Multiple studies show that the daily presence of an intensivist improves outcomes, including mortality and length of stay. There was no advantage to closed units. Disadvantages of open units: Disagreement about management plans Loss of control Advantages of open units Ability to care for a variety of patients (med, surg, etc) Ability to focus on critical care issues

31. Wear your name tags