Welcome to the TLC!
(last updated August 2012)
TLC Teams
• Attending (change weekly on Monday)
• Fellow (change monthly on the first)
• 2 Residents, typically from Anesthesia, Internal
Medicine, or Emergency Medicine
• 2-3 Interns, typically from Anesthesia, IM, EM,
OB/GYN, ENT, or Orthopedics
• Occasionally 4th year medical students
TLC Organization
• Critical Care Service (CCS) is comprised of two Medical ICU
teams.
• Most patients will be in the TLC but some “board” in Burn Unit
(B4/3), CCU (F4/M5), and NICU (F8/4).
• TLC is typically the primary service for their patients.
– We often serve as the primary service on Orthopedic and OBGYN.
– SICU, Vascular Surgery, Transplant Surgery admit to surgical ICU service which is
separate from TLC
– ICU is a multi-disciplinary field (doctors, nurses, pharmacists,
nutritionists, respiratory therapists, physical therapy,
occupational therapy).
TLC Staff
Dr. Wells (TLC
Director)
Dr. Coursin
Dr. Denlinger
Dr. Ehlenbach
Dr. Hammel
Dr. Jarjour
Dr. Ketzler
Dr. Lingenfelter
Dr. Maki
Dr. Regan
Dr. Runo
Dr. Sandbo
Dr. Sonetti
Dr. Hollatz
Dr. Goss
Dr. Leibel
Daily Schedule
• 7:00 a.m. (at the latest) – Arrive and round on your patients.
• 8:00 a.m. – X-ray rounds in the radiology conference room.
– Resident gives a one-sentence summary of case before the fellow
interprets the film.
• 8:30 a.m. – Team Rounds
– 1-2 computers per team for order-entry and data acquisition.
• Nurses start rounds
– Gives subjectives, vitals, drips ect.
– Present your patients (and sometimes your co-resident’s patients) to the
team.
• One sentence summary of patient , system-based Assessment & Plan
• All team members need to know about all patients, so keep extraneous work
and conversation to a minimum.
Daily Schedule
• 11:30 a.m.-4:30 p.m. – Daily work (new admits,
follow-up tests, call consults, etc.).
• 4:30 p.m. – Afternoon rounds with the on-call
team followed by intern-to-intern and senior-tosenior sign-out.
• 7:00 p.m. – On-call intern arrives and receives
check-out.
• 9:00 p.m. – Evening rounds with fellow,
residents, and charge nurses.
Paperwork
• All new admits and transfers need new orders.
– “IP-Intensive Care-Adult-Admission”
Admissions
• Attending physician is called for transfers from outside
facilities.
• Fellow is called for transfers from the floor and admissions
from the ED.
• Patient placement coordinated by sending and accepting
physicians, nursing manager, and charge nurses.
• Each patient will have a primary resident.
– Typically, both the senior and intern should be helping with the
admission of every patient (notes, orders, procedures, talking to families,
etc.).
• On call days, all team members may get new patients, whether or
not they are on night call.
Orders
• During rounds, one resident should be entering orders.
• Verbal and telephone orders are for emergencies only.
• Communicate with the nurse, pharmacist, HUC, etc. as much as
possible.
• Be thoughtful regarding orders.
– Not every patient needs every lab test every day.
– Few vent changes require an ABG.
• Order stats only when necessary.
• Before leaving, make sure your patients have appropriate a.m.
orders.
Procedures
• Safety is the primary concern.
– Person performing will be determined at the discretion of the fellow (and
ultimately, the attending).
• Consent is mandatory (except for emergent procedures).
• Nurses should be informed ahead of time for planned procedures.
• Nurses have a checklist to ensure sterile technique used for central
lines.
• Sterile technique should be used for arterial lines (waterproof, sterile gown
will protect you as well as the patient).
• All invasive procedures require a standard procedure note.
• NEJM.org has a series of very helpful instructional videos for our
common procedures.
• Wash your hands!
Procedure Carts
• In supply room.
• Needs to be returned in order to be re-stocked.
Ultrasound
• Two machines in storage
room (across from supply
room).
• When done clean, return, and
plug in.
Transfers to Floor / Discharges
• To transfer a patient out of the TLC, they need to be
accepted by another service.
– Accepting service writes orders.
• Anyone in ICU longer than 72 hours needs a transfer
summary.
• Discharge summary is the responsibility of primary
resident.
– Needed for deaths as well as discharges.
– Be sure to include letter to primary, and referring physicians.
Nursing
• Most nurses have more ICU experience than graduating critical
care fellows.
• Reliable source of information about patients in particular and
ICU in general.
• Able to monitor minute-to-minute changes in patients status.
• Must be present during rounds – find them!
• If a nurse questions an order or contacts you because of a patient
change, take their concerns very seriously.
• Two Care Team leaders each shift in TLC (one triage, one
staffing).
Respiratory Therapy
• Respiratory Therapists are in charge of all
ventilators and O2 equipment.
• They assist formation and implementation of
respiratory treatment decisions including
intubations, extubations, and codes.
• Only the respiratory therapists may make physical
ventilator changes. Residents place the order.
Pharmacists
• Pharmacists staff the TLC 24/7 and are an
invaluable asset for medication-related issues.
• On weekdays, there are two daytime pharmacists
and one will typically round with each team.
Social Worker
• Tracy Ryan is the TLC social worker.
• Very helpful regarding issues such as difficult
family dynamics and healthcare power of
attorney issues and are a valuable resource for
the families.
Nutrition
• There are several nutritionists working in the
TLC.
• Available for consultation and are often on
rounds.
Families
• Those working in the ICU are acclimated to the
critically ill, but for most patients and families, the ICU
is unfamiliar and frightening.
• Keep families updated.
• When families are frustrated or hostile, allow the fellow
or attending to speak with them to avoid mixed
messages.
• Have a low threshold for involving your fellow,
attending, and social worker in family communication.
Miscellaneous
Hamlet:
• Has
Nothis
eating
or
drinking
in
TLC.
fellow no feeling of his business, that he
• sings
Follow
isolation rules.
at grave-making?
• ICU is very different from most medicine
Horatio:
rotations.
Custom hath made it in him a property of easiness.
• If you have a question… ask it!
(From Hamlet,
Scene 1)
• If you need help…
ask Act
forV, it!
• A very dark sense of humor is a common side
effect of ICU work… be careful how it
manifests.
Resources
• Textbooks are too long to get through in one month, but can be read
throughout residency.
– Critical Care Medicine by Marini and Wheeler bases most teaching on physiologic
principles to lengthen its relevancy.
– The ICU Book by Marino is very popular among residents and fellows.
• Tarascon Internal Medicine & Critical Care Pocketbook may be a lifesaver…
literally!
• SCCM has guidelines as well as a powerpoint series regarding basic ICU topics.
– $25 to take the on-line course ($10 for SCCM members).
• The TLC website has key articles and links to useful sites.
– Link from Department of Medicine site (username: “tlcresidents”, password
“Brewers1”).
Questions ?