PRINCE GEORGE’S HOSPITAL CENTER
INTERNAL MEDICINE RESIDENCY PROGRAM
SECTION 7: CRITICAL CARE MEDICINE
This section has been reviewed and approved by the Chief, Division of Critical Care as well
as the Program Director, Internal Medicine Residency Program at Prince George’s Hospital
Center.
________________________
Chief, Division. Of Critical Care
______________________________
Program Director, Residency Program
I. Overview
Critical care medicine encompasses the diagnosis and treatment of a wide range of
clinical problems representing the extreme of human disease. Critically ill patients
require intensive care by a coordinated team, including a intensivist, subspecialists, and
allied health professional staff. At Prince George’s Hospital Center, there is an in house
Intensivist present in the ICU 24hrs a day, 7 days a week. However, in some settings,
the general internist /hospitalists may be the primary provider of care and may also
serve as a consultant for critically ill patients as well as on patients on surgical services.
Therefore, the general internist must have command of a broad range of conditions
common among critically ill patients and must be familiar with the technologic
procedures and devices used in the intensive care setting. The care of critically ill
patients raises many complicated ethical and social issues, and the general internist
must be competent in such areas as end-of-life decisions, advance directives, estimating
prognosis, and counseling of patients and their families.
Prince George’s Hospital Center is the only level 2 trauma center between Washington
DC and Baltimore. Residents have the option to follow trauma patients in the ICU though
are not mandated to do so. The ICU is a closed ICU with the intensivist following all
patients and making patient care decisions on them.
The mandatory rotation in Critical Care Medicine is designed as an educational
experience in the direct care, management, and triage of critically ill patients. The
resident will be exposed to a multi-disciplinary approach where he/she can develop
leadership and management skills in the orchestration of the care of these seriously ill
patients. The resident will be exposed and guided in the appropriate management and
monitoring of patients requiring mechanical, ventilation, pulmonary artery catheter,
continuous veno-venous hemofiltration (CVVH), and the use of technologies available
only in Intensive Care Units. The resident will have the opportunity to develop and
improve procedural skills necessary for physicians to effectively approach and manage
the critically-ill patient.
Resident responsibilities are detailed under section I of the Resident Handbook. The
rotation provides a wide variety of experience for the residents. This includes both
inpatient and emergency room consultations. The rotation is designed to provide training
and education in the specific aspects of critical care that will be most relevant to an
internist or hospitalilst.






The rotation will provide training in appropriate diagnosis and management of
critically ill patients, with special emphasis on hemodynamics, ventilation, and
bedside procedures.
Monitoring of patients on life sustaining devices (mechanical ventilation, CVVH),
performing and interpreting bedside procedures (swan ganz catheters, arterial
lines), use of pressors, sedatives etc.
Develop leadership and triage skills to manage patients in an acute settings, call
appropriate consults and perform appropriate tests.
The residents will participate in the consultation and management of patients on
the Medical floors and the emergency room under the supervision of an
intensivist.
Mechanism of diseases clinically relevant pathophysiology, clinical
manifestations, pharmocotherapy, and evidence-based management will be
emphasized.
The resident will demonstrate understanding of the principles, indications, utility
and interpretation of invasive and noninvasive methods of ventilation.
II. Principle Teaching Methods
This consists of frequent encounters with the medicine resident and making that person
accountable for performance. Primarily it consists of bedside rounds conducted every
morning by the inhouse intensivist for 2-4 hours. Here significant part of the teaching and
evaluation is carried out. The residents have frequent interaction with the intensivists
during the day for patient admissions and followup in the ICU. Rounds include short 1530 minute discussions on current medical topics driven by patient encounters and
initiated by residents, but completed by the attending physician on most days. Latest
information dealing with the topic as provided by literature search and pertinent articles
are made available.
The resident responsibilities are detailed under the section of Housestaff responsibilities
in Section I of the Resident Handbook. Typical daily schedule for the rotation is outlined
at the end of this section.
III. Strengths and Limitations
The critical care faculty consists of in-house intensivists as well as hospitalists that are
present in the ICU 24 hours a day as well as supervise admissions and consults on
medical patients. The intensivists have a strong commitment to patient care and resident
education. The patient and disease exposure is broad. The critical care’s units excellent
ancillary staff (nurses, respiratory therapists, nutritionists, case managers, Physical
therapists, Physician assistants) provide an excellent opportunity for learning a
multidimensional approach to patient management. Since the hospital is a trauma center
it provides a unique experience for interested residents in a community setting.
IV. Goals and Objectives
Residents will be required to take a pre and post ICU rotation test to evaluate medical
knowledge. The test will be conducted in the department of medicine online. The
residents will be given a login ID and password and will have to review the posted
materials and take the posted tests. This will be monitored by the program director or
his/her assignee.
Legend of Learning Activities
Learning Venues:
1. Direct patient care: supervised by attending physician
2. Management rounds with ICU attending
3. Teaching rounds, presentations in the ICU
4. Self Study
5. Core Department of Medicine Lecture Series
Evaluation Methods:
A. Attending evaluation
B. Direct clinical observation
C. Peer evaluation
D. Nurses evaluation
E. In-Training examination
F. Pre and post rotation test
The principle educational goals for the critical care rotation are listed by ACGME core
competencies.
Competency: Patient Care
Effectively evaluate and manage patients with critical
medical illness, including those on mechanical
ventilation and vasopressors
Effectively evaluate and manage patients with critical
illness
Improve physical examination skills and correlate
laboratory and hemodynamic data to establish patient
diagnosis and treatment plan
Insert central venous lines and arterial lines with
proper technique
Competency: Medical Knowledge (Also see
reading resources)
Expand clinically applicable knowledge base of the
basic and clinical sciences underlying the care of
patients with critical medical and surgical illness
Access and critically evaluate current medical
information and scientific evidence relevant to medical
and surgical critical care
Understand the physiologic and pathophysiological
principles of invasive hemodynamic monitoring
including indications
Access and critically evaluate current medical
information and scientific evidence relevant to acute
care.
 Pose answerable questions to solve dilemmas
in patient care
 Identify which type of article (primary
[diagnostic, treatment, prognostic, etc] vs.
secondary [reviews]) that is needed to answer
the particular question)
 Demonstrate the ability to use computer-based
Learning Venues
1, 2, 3, 4
Evaluation Method
A, B, E,F
1, 2, 4
A, B, E,F
1,6
A, B, C,F
1, 2
A, B. Add to procedure
log in new innovations
ALL
A, E,F
1, 2, 4
A, E,F
ALL
A, E,F
ALL
A, B, C, E,F
literature searches to identify references relevant
to patient problems
 Understand how individual patient demographics
may affect the application of medical literature.
Competency: Practice-Based Learning and
Improvement
Identify and acknowledge gaps in personal knowledge
and skills in the care of patients with critical medical
and surgical illness
Develop real-time strategies for filling knowledge gaps
that will benefit patients in the medical intensive care
unit
Resident will enter near misses and errors in the new
innovation system
Residents will accept feedback and work to improve
deficiencies
Resident will develop leadership and management
skills in the orchestration of the care of seriously ill
patients
Competency: Interpersonal Skills and
Communication
Communicate effectively with patients and families,
with emphasis on explanation of complex and
multisystem illness and the testing required to confirm
the diagnosis and appropriate therapy.
Communicate effectively with physician colleagues at
all levels with appropriate consultation when needed
 Senior residents must lead the interns through
role modeling and ensuring that management
plans are clearly communicated
Present patient information concisely and clearly,
verbally and in writing. Adhere to confidentiality
Communicate effectively with allied health care staff
to co-ordinate optimal patient care
Teach colleagues effectively
Communicate with members of healthcare team at
PGHC as well as other facilities, and patient families
to obtain information or arrange/co-ordinate patient
transfers
Competency: Professionalism
Demonstrate respect, compassion, integrity and
altruism towards patients, families, colleagues, and all
members of the health care team
Demonstrate sensitivity to confidentiality, gender, age,
cultural differences and disabilities
Identify deficiencies in peer performance. Senior
resident must provide appropriate supervision to the
interns
Seek to excel in clinical and scholarly work. Be well
prepared for rounds and on assigned readings. Senior
residents must ensure that interns have topics
1, 4
A, E,F
1,4
A, E
F
ALL
A, B, C, E
ALL
A, B, C, D
1,2
A, C, D
1, 2
A, C, D
1, 2
A, B, C, D
1, 2
A, B, C, D
1,4
1, 2
A, C
A, B, C, D
1, 2, 5
A, B, C, D
1, 2, 5
A, B, C, D
1,4
A, B, C
ALL
A, B
assigned and must lead the team in evidence based
learning.
Maintain a level of inquiry and actively seek out new
information by reading to enhance knowledge
Competency: Systems-Based Practice
Understand and utilize the multidisciplinary resources
necessary to care optimally for ICU patients and the
limitations of various practice environments.
Collaborate with other members of the health care
team to assure comprehensive ICU patient care
Use evidence-based, cost-conscious strategies in the
care of ICU patients
ALL
A, B, C, D
1, 2, 3, 4
A, C
1, 2
A, C
1, 2
A, C
V. Educational Content
A. Central Nervous System
1) Recognition and Acute Management of:

Acute stroke, stroke in evolution (ischemic, hemorrhagic)

Intracranial hypertension

Drug overdose and acute intoxication

Delirium tremens

Status epilepticus

Encephalitis, meningitis

Spinal cord injury, Cord compression

Intracranial space occupying lesions

Myesthenic crisis

Guillian Barre syndrome

Acute Hydrocephalus

Brain death evaluation

Persistent vegetative state
2) Learn the differential diagnosis of altered mental status and coma and the
diagnostic and therapeutic interventions
B. Cardiovascular System
1) Learn the management of Acute Chest Pain/Ischemia and Infarction including:

The role of thrombolytics

The role of invasive procedures

EKG interpretation

Understand the appropriate situations for ordering echocardiograms,
cardiac catheterizations
2) Recognition and acute management of:

Shock (Cardiogenic, Hypovolemic, Distributive and Obstructive Shock)

Life threatening cardiac arrhythmias

Cardiogenic Pulmonary edema

Acute cardiomyopathies

Hypertensive emergencies





Phaeochromocytoma
Cardiac Tamponade
Acute Myocardial Infarction
Aortic dissection
Acute valvular insufficiency
3) Principles of:

Understand the Pathophysiology of Cardiogenic, Hypovolemic, Distributive
and Obstructive Shock

Learn cardiopulmonary resuscitation including Intravenous fluid
resuscitative measures, Inotropic and Vasopressor support

Observe the technique of right heart catheterization and the interpretation
of hemodynamic profiles

Arterial, central venous, and pulmonary artery catheterization and
monitoring

Understand the pathophysiology of Multi-organ Dysfunction Syndrome

Cardiovascular physiology in the critically ill patient
C. Respiratory
1) Recognition and acute management of:
 Acute and chronic respiratory failure
 Status asthmatics
 Smoke inhalation and airway burns
 Upper airway obstruction, including foreign bodies and infection
 Near drowning
 Adult respiratory distress syndrome
 Pulmonary embolism
 CO2 narcosis, severe COPD exacerbation
 Pneumonia and Pleural effusions
2) Respiratory Distress and Failure:
 Understand .the pathophysiology of hypercapnea and hypoxic respiratory
failure states
 Understand the pathophysiology of status asthmaticus
3) Interpretation of:

Pulmonary function tests including bedside Spirometry

Arterial blood gas analysis
4) Principles and application of:

Various modes of supplemental oxygenation

Mechanical ventilation (invasive and non-invasive) including indications,
modes, complications, and weaning and extubation

Observe endotracheal Intubation techniques

Learn the techniques of conscious sedation

Understand the indications for placement of chest tubes and performing
fiber optic bronchoscopy
D. Gastrointestinal Disorders
1) Recognition and Acute Management of:






2)
3)
4)
5)
Gastrointestinal bleeding
Learn the pathophysiology and management of Hepatic failure
Perforation of viscus
Learn the pathophysiology, differential diagnosis and therapy for acute
pancreatitis and its complications
Mesenteric infarction
Cirrhosis and hepatic encephalopathy
Principles of prophylaxis against stress ulcer
Learn the appropriate indication for upper and lower endoscopy
Indications and insertion of PEG tube, G tube, J tube
Principles of liver transplant
E. Metabolic and Endocrine
1) Recognition and Acute Management of:

Hypoadrenal crisis (addisonian crisis)

Diabetes insipidus

Diabetic ketoacidosis

Hyperosmolar coma

Myxedema coma

Thyrotoxicosis
2) Principles of Alimentation

Learn the indication and formulation for parental nutrition

Learn to calculate caloric needs

Placement of nasogastric feeding tubes

Enteral feeds and its contraindications

Parenteral nutrition and its advantages and disadvantages
F. Renal
1) Learn the differential diagnosis, pathophysiology and therapeutic management of
acute renal failure
2) Recognition and Acute Management of:

Fluid and electrolyte disturbances

Acid-base disorders

Learn the clinical manifestations and management of common electrolyte
disorders including hyper/ hypo kalemia, natremia and calcemia
3) Principles of:

Drug dosing in renal failure

Fluid and electrolyte therapy in the critically ill patient

Dialysis – including CVVH
G. Infectious Disease
1) Recognition and Acute Management of:

Learn the pathophysiology and management of Sepsis, SIRS, Septic shock

Meningitis, encephalitis

Hospital-acquired infections including ventilator associated and line
infections

Opportunistic infections, including
immunodeficiency syndrome
those
associated
with
acquired
2) Principles of:

Antibiotic selections and dosage schedules for the critically ill patient

Infection risks to healthcare workers

Learn procedures to prevent the spread of drug resistant organism in the
ICU
H. Hematologic Disorders
1) Recognition and Acute Management of:

Defects in hemostasis including DIC

Hemolytic disorders

Hematologic dysplasias and their complications

Sickle cell crisis

Thrombotic disorders including TTP
2) Principles of:

Anticoagulation and fibrinolytic therapy

Blood component therapy

Exchange transfusions

Plasmapheresis for acute disorders including neurologic and hematologic
diseases
I.
Principles of Sedation, Analgesia, and Neuromuscular Blockade in Critically Ill
Patient
1) Indications, induction, management
2) Adverse effects
3) Titration
4) Reversal
J. Monitoring and Biostatistics
1) Prognostic indices like:

Acute Physiology and Chronic Health Evaluation (APACHE score)

Therapeutic Intervention Scoring System
K. Ethical and Legal Aspects of Critical Care
1) Do-not-resuscitate orders
2) Principles of informed consent
3) Rights of patients, living wills
4) Withholding and withdrawing life support, death and dying
5) Advance directives (Patient Self Determination Amendment of 1991)
6) Comfort care
7) Breaking bad news to patients and families, Understanding the effect of lifethreatening illness on patients and their families
8) Organ donation
L. Miscellaneous
1) Transport of the Critically Ill Patient

Stabilization

Equipment and monitoring

Co-ordination of care with tertiary care center
2) Principles of Resuscitation and Postoperative Management of the Patient With
Acute Traumatic Injury
3) Critical Illness in Pregnancy
M. Procedures
1) Master Advanced Cardiac Life Support
2) Arterial and Central venous line placement
3) Mechanical Ventilation
4) Observe the technique for endotracheal intubation
5) Observe the technique for placement of a Swan Ganz Catheter
VI. Guidelines for the Organ/ Systems Approach for Patient Review for Resident’s
Notes
Residents are strongly encouraged to use the following guidelines to incorporate all
relevant patient care information in their daily progress notes in the ICU. An OrganSystems based approach allows a thorough follow up of all active issues regarding the
patients and decreases chances of missing out on important patient care information
and treatment plan.
A. Neurology
1) Examination

GCS

Mental status, including psychiatric components, psychosis,depression

Cranial nerves, Muscle strength, reflexes, cerebellar signs, gait, focal
changes
2) Sleep

# of hours

Sleep-wake cycle present
3) Sedation – type and amount
4) Conclusion

Whether adjustments are needed

Review medications/conditions

Activity – to reinstate sleep-wake cycle
B. Respiratory
1) Examination
2) CXR

Interval changes

ET tube placement
3) Sputum production, Pertinent culture and gram stain reports
4) Day # if intubated
5) Mechanical ventilation settings

AC

IMV



PS
FiO2
PEEP/CPAP
6) Minute Ventilation

Respiratory rate

Spontaneous TV, Set rate

ABG on ventilator setting
7) Impression – include input from the respiratory therapist
8) Recommended changes

Inhalers

Steroids

Repeat cultures

Diagnostic studies or interventions

Ventilator changes
9) PE prophylaxis

Heparin

SCDs
C. Cardiovascular
1) Examination
 Heart rate
 Rhythm
 Ischemic events
 Laboratory evaluation
 Isoenzymes, ECG
2) Hemodynamics
 MAP – and 24-hour trend
 CI, SVRI, HR
 PCWP
 Pressors, Inotropic agents
 Impression of fluid balance (to be detailed in Renal)
 Impression of hemodynamic profile
 NL, low output state or hyperdynamic
3) Recommendations
 Need for hemodynamic monitoring
 Adjustment of pressors or inotropic agents
 Antihypertensive regiment
 Antiarrhythmic agents
D. Renal and Electrolytes
1) Net fluid balance (in part covered with Cardiovascular System),
 I/O
 Total IV rate, including intake from meds and continuous drips
 Weight with review of weights of last 3-4 days; Admission and goal weight
2) . Recommendations
 Electrolytes, creatinine reviewed and appropriate replacements
 Potential nephrotoxic agents
 Readjustment of dosing of medication
 Type of fluids/fluid rate (Comment if not adjusted with cardiovascular)
 Review Net fluid balance
 Goal for next 24 hours or by liters
E. Gastrointestinal
1) Complaints from patients
2) Enteral feeds – type and rate or if parental nutrition
 Whether goal reached
 Total calories per day
 Residual or NG output per shift
3) Bowel movements, vomiting, diarrhea
 Quantity
 Guiac test
4) Examination
 Tenderness – site
 Abdominal girth
 Bowel sounds
5) Impression and Recommendations
 Include adjustment in rate of nutrition
 Need for motility agents
 GI prophylaxis – Carafate vs. H2 Blocker
 Indication and interpretation of labs and diagnostic studies
F. Endocrine
1) Glucose
2) Thyroid function, Cortisol
3) Insulin requirements
4) Recommendations
G. Infectious Disease
1) Pertinent findings on examination
 Fever curve
 Wound site
2) Laboratory findings
 Microbiology gram stain culture sensitivities
 WBC and differential
 Antibiotic levels
3)
Source of infection
 Lung, abdomen, urinary tract, etc
 Line related: central; a-line; Swan Ganz
 Lines/Day #
4) Antibiotics
 Dose and interval
 Detail rational use for each antibiotic
 Holes in coverage
5) Recommendation
 Additional cultures
 Change of therapy or dosing, including stop dates of antibiotic)
 Additional diagnostic studies
H. Hematology
1) Labs: compare with previous days and follow trends
2) Number of transfusions and type of blood product
3) Etiology of anemia, thrombocytopenia,
4) Coagulopathy
5) Recommendations
I.
Dermatology
1) Rashes
2) Wounds
3) Decubiti
4) Recommendations
5) Bed: special type needed
6) Local care
J. Ethical/Social Issues
K. Miscellaneous
1) Physical therapy
2) Occupational therapy – splint – foot and hand
3) Speech therapy and swallow evaluation
4) Cognitive evaluation
5) Nursing issues
6) Laboratory data and orders and medication review
VII. Recommended Readings
All residents are also encouraged to read the Critical Care Section of the MKSAP during
their rotation and use MDConsult and Up To Date on a case by case basis. A package of
reading materials, articles will be handed out to each resident at the beginning of the ICU
rotation.
VIII. Additional Reading Materials and Resources
All residents will have access to MDConsult, Pubmed/ MEDLINE searches on various
computers throughout the hospital. Residents are strongly encouraged to use these
resources for practice of evidence based medicine on a case by case basis.
A. Shock
1) Hotchkiss,RS & Karl,IE The Pathophysiology and Treatment of Sepsis NEJM
2003, 348(2):138-150
2) Cross AS & Opal, SM A New Paradigm for the Treatment of Sepsis: Is It Time to
Consider Combination Therapy? Annals of Internal Medicine 2003; 138:502-505
3) Dellinger, RP et al. Surviving Sepsis Campaign guidelines for management of
severe sepsis and septic shock Critical Care Medicine 2004; 32 (3) 858-873
4) Hollenberg, SM et al. Practice parameters for hemodynamic support of sepsis in
adult patients: 2004 update Critical Care Medicine 2004; 32 (9):1928-1948
5) The SAFE Investigators, A Comparison of Albumin and Saline for Fluid
Resuscitation in the Intensive Care Unit NEJM 2004; 350 (22): 2247-2296
6) Hameed, SM, et al Oxygen Delivery. Critical Care Medicine 2003; 31(12): S658667
7) Rivers, E et al, Early Goal-Directed Therapy in the Treatment of Severe Sepsis
and Septic Shock, NEJM 2001: 345(19): 1368-1377
8) Read CA. Maximizing Oxygen Delivery When Resuscitating Patients from Shock.
J Crit Illness 1995; 10(1): 757-770
B. Respiratory Failure & Mechanical Ventilation:
1) Piantadosi,CA & Schwartz,DA, The Acute Respiratory Distress Syndrome.
Annals of Internal Medicine 2004; 141: 460-470
2) The NHLBI ARDSNET, Higher versus Lower Positive End-Expiratory Pressures
in Patients with the Acute Respiratory Distress Syndrome. NEJM 2004;
351(4):327-336
3) Gajic, O et al Ventilator-associated lung injury in patients without acute lung
injury at the onset of mechanical ventilation. Critical Care Medicine 2004; 32(9):
1817-1823
4) Tobin, MJ, Advances in Mechanical Ventilation, NEJM 2001; 344(26): 1986-1996
5) Marini, JJ & Gattinoni, L, Ventilatory Management of acute respiratory distress
syndrome: A consensus of two. Critical Care Medicine 2004; 32(1):250-255
6) Liesching, T et al Acute Applications of Noninvasive Positive Pressure
Ventilation. Chest 2003; 124:699-713
C. Critical Care Cardiology
1) Schulman,SP & Fessler,HE, Management of Acute Coronary Syndromes.
American Journal of Respiratory and Critical Care Medicine 2001; 164(6):917922
2) Zimetbaum,PJ & Josephson, ME, Use of the Electrocardiogram in Acute
Myocardial Infarction. NEJM 2003; 348:933-40
3) Varon,J & Marik,P, The Diagnosis and Management of Hypertensive Crises
Chest 2000; 118:214-227
4) Roden,DM, Drug-Induced Prolongation of the QT Interval NEJM 2004;350:10131022
5) Spodick, DH, Acute Cardiac Tamponade. NEJM 2003; 349:684-690
D. Gastroenterology
1) Proctor, D. Critical Issues in Gastroenterology. Clinics in Chest Medicine
2003;24:623-632
2) Gines,P et al, Management of Cirrhosis and Ascites.NEJM 2004;350:1646-54
3) Sharara,AI & Rockey,DC, Gastroesophageal Variceal Hemorrhage NEJM 2001;
345(9):669-681
4) Barkun,A et al Consensus Recommendations of Managing Patients with
Nonvariceal Upper Gastrointestinal Hemorrhage. Annals of Internal Medicine
2003; 139:843-857
5) Lee WM. Acute Liver Failure. N Engl J Med 1993;329:1862-72
6) Steinberg W, Tenner S. Acute Pancreatitis N Engl J Med. 1994;330:1198-1210
7) Kelly Cp, Pothoulakis C, LaMont JT. Clostridium Difficile Colitis N Engl J Med
1994;330:257-62
E. Hematology
1) Drews, R. Critical Issues in Hematology: anemia, thrombocytopenia,
coagulopathy, and blood product transfusions in critically ill patients. Clinics in
Chest Medicine 2003; 24: 607-622
2) Hebert et al, A Multicenter, Randomized, Controlled Clinical Trial of Transfusion
Requirements in Critical Care NEJM 1999; 340(6):409-417
3) Raghavan,M & Marik, P, Anemia, Allogeneic Blood Transfusion and
Immunomodulation in the Critically Ill. Chest 2005; 127:295-307
F. Neurology
1) Fulgham, JR et al, Management of Acute Ischemic Stroke. Mayo Clin Proc 2004;
79(11):1459-1469
2) Rose, JC & Mayer, SA, Optimizing Blood Pressure in Neurologic Emergencies
Neurocritical Care 2004; 1(3):287-300
3) Marik,P & Varon,J, The Management of Status Epilepticus. Chest 2004;126:582591
4) How to Determine Brain Death in Adults: New Guidelines. J Crit Illness
1995;10(10):669-70
G. Nephrology:
1) Peixoto,A. Critical Issues in Nephrology. Clinics in Chest Medicine 2003; 24: 561581
2) Thadhani R, Pascual M, Boneventre JV. Acute Renal Failure. N Engl J Med.
1996;334:1448-1460
3) Albright,RC, Acute Renal Failure: A Practical Update. Mayo Clin. Proc.
2001;76:67-74
4) Esson,ML & Schrier,RW, Diagnosis and Treatment of Acute Tubular Necrosis.
Anals of Internal Medicine 2002;137:744-752
5) Schrier,RW & Wang,W, Acute Renal Failure and Sepsis, NEJM 2004;
351(2):159-169
6) Teehan,GS et al, Update on Dialytic Management of Acute Renal Failure,
Journal of Intensive Care Medicine 2003;18(3):130-138
H. Endocrinology
1) Van den Berghe GH. Role of intravenous insulin therapy in critically ill patients.
Endocr Pract. 2004 Mar-Apr;10 Suppl 2:17-20
2) Goldberg,P et al, Critical Issues in Endocrinology. Clinics in Chest Medicine
2003; 24:583-606
3) Ringel,MD, Management of Hypothyroidism and Hyperthyroidism in the Intensive
Care Unit. Critical Care Clinics 2001; 17(1):59-74
4) Magee,MF & Bhatt,BA, Management of Decompensated Diabetes: Diabetic
Ketoacidosis and Hyperglycemic Hyperosmolar Syndrome. Critical Care Clinics
2001;17(1): 75-106
5) Cooper,MS & Stewart,PM, Corticosteroid Insufficiency in Acutely Ill Patients.
NEJM 2003; 348(8):727-734
6) Dorin,RI et al, Diagnosis of Adrenal Insufficiency. Annals of Internal Medicine
2003;139:194-204
7) Hamrahian,AR, et al Measurements of Serum Free Cortisol in Critically Ill
Patients. NEJM 2004; 350(16):1629-1638
I.
Nutrition
1) Chan, S et al, Nutrition Management in the ICU, Chest 1999;115:145S-148S
2) Cerra,FB et al, Applied nutrition in ICU Patients: A Consensus Statement of the
American College of Chest Physicians. Chest 1997; 111:769-778
J. Sedation
1) Jacobi,J et al, Clinical practice guidelines for the sustained use of sedatives and
analgesics in the critically ill adult. Critical Care Medicine 2002;30(1):119-141
2) Ely,W et al, Monitoring Sedation Status Over Time in ICU Patients JAMA 2003;
289(22):2983-2991
K. Ethics & End of Life
1) Truog,RD et al, Recommendations for end-of-life care in the intensive care unit:
The Ethics Committee of the Society of Critical Care Medicine. Critical Care
Medicine 2001; 29(12): 2332-2348
L. Toxicology
1) Mokhlesi,B et al, Adult Toxicology in Critical Care Part I: General Approach to the
Intoxicated Patient. Chest 2003; 123(2):577-592
2) Mokhlesi, B et al, Adult Toxicology in Critical Care: Part II: Specific Poisonings.
Chest 2003; 123(3):897-922
3) Kosten,TR & O’Connor,PG, Management of Drug and Alcohol Withdrawal NEJM
2003; 348(18):1786-1795
PRINCE GEORGE’S HOSPITAL CENTER
INTERNAL MEDICINE RESIDENCY PROGRAM
ICU TEAM SCHEDULE
PRINCE GEORGE’S HOSPITAL CENTER
INTERNAL MEDICINE RESIDENCY PROGRAM
ICU TEAM SCHEDULE
ICU team will comprise of 3 interns + a 2nd year resident + SMR (3rd year resident)
Interns and 2nd year resident rotate q 4 days (24 hour call) and SMR is on call q 4 (8:00 am to
8:00 pm except when the call falls on a Friday or a Saturday and then it will be 24 hour).
Normal ICU Day (Mon – Fri)
07:30 – 8:00
Pre-rounds (Interns and the resident round with SMR). Interns and the
resident are expected to be ready with their patient’s labs, exam and
assessment at the start of the pre-rounds.
08:00 – 11:00 am*
Bedside rounds with the ICU attending*
11:00 – 11:30 am
Sign off rounds (post call intern signs off to the interns & SMR)
(Depending on when interns coming in to write notes in am, maximum
hour of work is 30 hrs continuous)
12:00 – 12:30pm
Tutorials (Mon, Wes and Fri)#
Case Discussion (Tues – Thurs)^
12:30 – 1:00 pm
X-ray rounds
1:00 or 2:00 pm
Post call intern signs out and goes home, depending on the time at which
starting in the mornings. If coming in at 5:00 am then need to leave at the
latest at 1:00 pm
2:00 – 4:15 pm
4:15 – 5:00 pm
Do procedures, admissions, consults on patients.
Evening rounds (SMR rounds with the intern on call)
* During the rounds if any new consult/admission comes, the pre call intern will go and see the
consult/admission and will discuss with the SMR. After rounds the on call intern will take over
the case. This is to avoid interruption during the rounds as both post and on-call interns need to
be present during the rounds.
# tutorials to be conducted by SMR for the interns
^Intern or resident presents the case during case discussion.
ICU SMR will write brief admit notes on all admissions to the ICU.