ROTATION INFORMATION
DEPARTMENT OF ANESTHESIA
RESIDENCY TRAINING PROGRAM
UNIVERSITY OF MANITOBA
INTRODUCTION
The Cardiovascular Intensive Care Unit (CVICU) at the St. Boniface General Hospital provides postoperative care to all cardiac surgical patients at the University of Manitoba.
This is a full intensive care unit providing all aspects of cardiovascular and respiratory support. Residents will provide care for the entire spectrum from fast-track patients through to complicated postoperative. They will have the opportunity to gain experience with invasive monitoring, pharmacologic cardiovascular support, coagulopathy, and facilitated recovery.
GOALS AND OBJECTIVES
The University of Manitoba Training Program for Residents in Anesthesia has been developed in accordance with the guidelines of the Royal College of Physicians and
Surgeons of Canada.
The following Rotation Specific Goals and Objectives for CVICU at the St. Boniface
General Hospital site, provide additional emphasis to particular components of the
Overall Program Goals and Objectives.
Please refer also to the National Curriculum for Canadian Anesthesia Residency for more information on expected knowledge and skills.
All appropriate Program Goals and Objectives also apply to this rotation.
1) Medical Expert/Clinical Decision Maker
By the end of the training in CVICU, the resident will be able to perform the following with respect to patients after all types of cardiac surgery (excluding transplant) with all varieties of pre-existing conditions: a) Predict the expected sequence of events in the first 96 hours of recovery after uncomplicated cardiac surgery. b) Describe the neurohumoral response to injury and cardiopulmonary bypass in particular. c) Describe the important principles involved in promoting perioperative recovery, and provide and management plan designed to facilitate recovery. d) Identify risk factors for prolonged postoperative cardiorespiratory support and complications in the cardiac surgical population
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e) Obtain and utilize history, physical and laboratory findings to identify, characterize and grade the severity cardiovascular problems including: i) Myocardial ischemia ii) Tamponade iii) Valvular dysfunction iv) Arrhythmias v) Shock states, including type and underlying cause f) Describe the typical echocardiographic findings in each of the above situations g) Create and defend a rational treatment plan including endpoints, alternatives and relative advantages and disadvantages for all of the above problems, based on the physiology and natural history. h) Obtain and utilize history, physical and laboratory information to identify, characterize and assess the severity of respiratory abnormalities including: i) Respiratory failure ii) Hypoxemia iii) Hypercarbia iv) Bronchospasm v) Pulmonary parenchymal infection vi) Pulmonary edema i) Create and defend a rational treatment plan including endpoints, alternatives and relative advantages and disadvantages for all of the above problems, based on the physiology and natural history. j) Identify the need for respiratory support based on history, physical and laboratory findings. k) Select appropriate respiratory support including supplemental oxygen, CPAP,
BIPAP, endotracheal intubation and positive pressure ventilation based on the indications, contraindications and underlying physiology. l) Select mode and settings for positive pressure ventilation, and defend the selection based on respiratory mechanics. m) Appropriately wean respiratory support. n) Obtain and utilize history, physical and laboratory information to identify, characterize and assess the severity of disorders of coagulation. o) Provide appropriate management of coagulopathy. p) Identify and appropriately manage Heparin induced thrombocytopenia. q) Obtain and utilize history physical and laboratory information to identify perioperative neurologic injury. r) Utilize consultants appropriately to manage perioperative neurologic injury.
2) Communicator
By the end of the training in CVICU, the resident will be able perform the following: a) Establish a therapeutic relationship with patients and/or family members as appropriate, including i) Encouraging patient participation in decision-making, and to do this in consultative, elective, and emergent situations, and in challenging situations
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such as patient anger, confusion, language or ethno-cultural differences, or extremes of age ii) Listening to patients, answering their questions, and decreasing their anxiety iii) Demonstrate respect and empathy in relationships with patients b) Gather sufficient information from the patient, family members, and/or medical personnel to identify all issues that will have implications for perioperative management i) medical and surgical status of the patient ii) patient expectations, beliefs, and concerns (in addition to medical problem information), while also considering the influence of age, gender, and ethnocultural, spiritual, and socio-economic background on the medical problem c) Impart sufficient information to patients and appropriate family members or delegates to allow a complete understanding of the status of the patient and the expected course of events d) Obtain complete informed consent for care
3) Collaborator
By the end of the training in CVICU, the resident will be able perform the following: a) Consult other physicians and allied health professionals in order to provide optimal perioperative care b) Coordinate care of cardiac patients with other members of ICU and surgical team. c) Communicate effectively with other tem members d) Manage urgent and crisis situations such as cardiac arrest, trauma, anaphylaxis, and malignant hyperthermia, as a team member or a team leader e) Resolve conflicts or provide feedback where appropriate
4) Manager
By the end of the training in CVICU, the resident will be able perform the following a) Utilize personal and outside resources effectively to balance patient care, continuing education, practice, and personal activities b) Use limited health resources appropriately including management of i) time for patient care, teaching and personal learning ii) expenses related to testing, treatments, and technology iii) human resource and financial implications of the intensive care environment
5) Health Advocate
By the end of the training in CVICU, the resident will be able perform the following a) Recognize individual and systemic issues with an impact on postoperative care and safety of the cardiac patient
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b) Communicate identified concerns and risks to patients, other health care professionals, and administration as applicable c) Intervene on behalf of individual patients and the system as a whole regarding quality of care and safety
6) Scholar
By the end of the training in CVICU, the resident will be able perform the following a) develop and maintain a personal learning strategy which will continue to maintenance of certification b) Seek out and critically appraise literature to support clinical care decisions and practice evidence based application of new knowledge c) Contribute to the appropriate application, dissemination, and development, of new knowledge d) Teach medical students, other residents, faculty members, other health professionals, and patients using the principles and methods of adult learning
7) Professional
Throughout the training in CVICU the resident shall: a) deliver the highest quality patient care with integrity, honesty, and compassion b) Fulfill the ethical and legal aspects of patient care c) Maintain patient confidentiality d) Demonstrate appropriate interpersonal and professional behaviour e) Recognize personal limits through appropriate consultation (with staff supervisors, other physicians, and other health professionals) and show appropriate respect for those consulted f) Recognize conflict in patient care situations, professional relationships, and value systems, and demonstrate the ability to discuss and resolve differences of opinion. g) Accept constructive feedback and criticism, and implement appropriate advice h) Continually review personal and professional abilities and demonstrate a pattern of continuing development skills and knowledge through education
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i) Identify problems of physical and mental health including chemical dependence, stress, and depression, and ways to deal with these problems in oneself and others
CLINICAL RESPONSIBILITIES
The ICCS rotation consists of two sections. The first week is the perioperative portion under the supervision of the ICCS anesthesiologist. In this portion of the rotation, the resident will focus on the facilitated recovery of Track 1 patients (formerly referred to as fast-track). The Intensive Care portion is the final three weeks and is supervised by the
ICCS intensivist. During this portion, the resident will focus on the intensive care management of more complicated cardiac patients.
Perioperative Portion
1) Daily a) Patient assessment: The resident will assess each patient at the beginning of the day. Rounds in the Track 1 unit begin at 1030. The resident should have assessed all of the patients prior to that in order to present a concise summary at the morning rounds. The resident shall communicate with the OR teams in order to complete scoring for patients to determine their suitability for Track 1 or 2. The resident will complete an admission assessment of each new patient arriving in the unit. The resident will again present a summary of each patient at sign-out rounds, which are timed to end by 1800. In addition to the assessments noted above the resident will also followup on endpoints identified in morning rounds, at critical points in the recovery process or in response to problems arising. b) Treatment planning: For each patient, the resident will generate a management plan incorporating the planned goals and endpoints for therapy, potential complications for surveillance and the expected course. c) Communication with Attending staff: It is the responsibility of the resident to ensure that the treatment plan is discussed with and approved by the attending anesthesiologist before proceeding. d) Documentation: The resident will be responsible for entering a daily note in the chart to document including patient progress and a clear treatment plan. Each patient should also have a note written to document any siginificant deviations from the expected care plan, any procedures done, and upon transfer from the
Track 1 unit.
2) Call a) There is no call on the ICCS rotation .
Intensive Care Portion
1) Daily a) Patient assessment: The resident will assess each patient at the beginning of the day. Rounds in the Track 2 unit begin at 0800. The resident should have assessed all of the patients prior to that in order to present a concise summary at the morning rounds. The resident shall communicate with the OR teams in order to complete scoring for suitability for Track 1 or Track 2. The resident will complete an admission assessment of each new patient arriving in the unit. The
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resident will again present a summary of each patient at sign-out rounds, which are timed to end by 1800. In addition to the assessments noted above the resident will also followup on endpoints identified in morning rounds, at critical points in the recovery process or in response to problems arising. b) Treatment planning: For each patient, the resident will generate a management plan incorporating the planned goals and endpoints for therapy, potential complications for surveillance and the expected course. c) Communication with Attending staff: It is the responsibility of the resident to ensure that the treatment plan is discussed with and approved by the attending intensivist before proceeding. d) Documentation: The resident will be responsible for entering a daily note in the chart to document including patient progress and a clear treatment plan. Each patient should also have a note written to document any significant deviations from the expected care plan, any procedures done, and upon transfer from the
Track 1 unit.
2) Call
There is no call on the ICCS rotation.
OTHER RESPONSIBILITIES
1) Teaching
Residents shall participate in the clinical teaching of medical students, junior residents, and paramedical trainees that are slated to work with them.
2) Anesthesia Talk Rounds and Grand rounds
Resident will attend all talk rounds and Grand rounds that occur at their site during their rotation with the following exceptions i) While on holidays ii) Wednesday morning talk rounds when on call Wednesday evening iii) Illness
3) Mini rounds presentations i) Track 1- the resident will be assigned a topic for a short powerpoint presentation on the last day of the Track 1 portion. This may consist of an article review or case summary. ii) Track 2- The resident will also complete a short powerpoint presentation om the last day of the Track 2 portion. This may consist of an article review, case summary, or brief literature review.
LEARNING RESOURCES
During this rotation, the following resources will be available to residents in addition to those available at all times through the University Department:
1) Clinical teaching- The most important learning resource during clinical rotations is the direct teaching that occurs during discussion with staff of the management of actual cases, and topics of interest. The quality of this discussion is enhanced by communication in advance to generate a teaching plan.
2) Site Library- each tertiary site has a collection of current textbooks relevant to the pattern of practice of the site
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3) Computer access- each tertiary site has computer access within the OR for resident use in accessing literature
4) Echocardiography library- a collection of echo images of key clinical situations will be available for review. These may also be used in support of the minirounds of applicable.
PREREQUISITE
Each resident rotating on the ICCS must have completed at least one rotation in the surgical intensive care at HSC or combined unit at SBGH. S/he also must have completed at least one rotation of cardiac anesthesia.
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