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.