Welcome to the Surgical ICU Rotation at Orlando Regional Medical Center!

Please take a few moments to review the following orientation information prior to beginning your rotation in the Surgical Intensive Care Units. Our intent is to make this rotation both educational and personally rewarding for you.

One's first encounter with the intensive care unit (ICU) can be overwhelming. The severity of illness, complex life-support systems and monitors, potent medications, and complex ethical issues can easily obscure the most important element in the ICU: the patient. It is no wonder that many medical students, residents, and even attending physicians find the ICU a confusing, intimidating, and challenging place.

Comprehensive ICU management is a 24-hour a day process. The ultimate goal of this labor intense commitment to care is to identify signs of physiologic deterioration early such that appropriate interventions can be instituted before progressive multisystem organ failure and death can develop. ICU care is best practiced using a "multidisciplinary" team approach. The Surgical Critical Care (SCC) team consists of board-certified surgical attendings; board-eligible/certified surgical critical care fellows; general surgery and emergency medicine residents; and medical or physician's assistant students. Non-physician members of the team include ICU nurses; respiratory therapists; pharmacists; physical, occupational, and speech therapists; nutritional support team members; and social workers among others. We approach each patient using a methodical, organ system-based approach that requires intensive patient evaluation, cost-effective laboratory and radiologic testing, and a detailed knowledge of the most likely complications for the patients' underlying pathophysiology and disease process.

Many residents and medical students approach their ICU rotation with the perception that they are here to perform procedures: to intubate, to place central lines, to turn ventilator knobs. This is a superficial approach to an opportunity that many find to be one of their most rewarding and educational learning experiences. Rest assured that you will have ample opportunity to perform a variety of procedures during your rotation. More importantly, however, you will be exposed to a broad range of critical care issues and have the opportunity to improve your skills as a primary physician caring for critically ill patients.

There is a tremendous amount of information to be learned and experience gained while in the ICU. You will be amazed at the amount of knowledge you will gain during your time on the SCC Service. The primary purpose of this website is to bring this information together in one, readily available location. We encourage you to visit this website often and take advantage of the online lectures, guidelines, and case presentations it contains. Our intent is to help you achieve the following four goals:

The remainder of this webpage is divided into the various phases of your time in the ICU ("Pre-Rotation", "During Your ICU Rotation", and "Post-Rotation"). It also lists the Educational Objectives for the rotation, the Resident and Student Responsibilities, and some very helpful tips for "surviving" the rotation. Please take a moment to familiarize yourself with this information including the requirements of each phase of the ICU rotation.


PRE-ROTATION

Approximately two weeks before you are scheduled to start your time on the SCC Service, you will be contacted and referred to this page of the website. Take a moment to review both the ICU Educational Objectives and the Resident / Student Responsibilities. It would also be a good idea to review the contents of this website. It has been designed to provide you with access to a variety of teaching materials, evidence-based medicine guidelines, instructional tutorials, and interactive case presentations 24 hours a day, 7 days a week from any computer in the hospital. You may also review the materials on your home computer via the Internet at your leisure. The educational materials contained within this website supplement the didactic lectures and bedside teaching you will receive while on the rotation and are essential to your daily care of patients. When you have a question as to what to do for your patient, chances are the answer to your question is on surgicalcriticalcare.net!

Prior to beginning your ICU rotation, please complete the Pre-Rotation Self-Assessment Learning Test. This online test gives you an initial glimpse into the types of information that you will be learning during your rotation, allows you to assess your current knowledge of critical care, and helps you identify areas where you may want to direct your reading while on the service. The results of this test also help us to ensure that the teaching you receive while on the rotation is both appropriate and comprehensive. Completing this test is required to begin the rotation.

PRE-ICU ROTATION CHECKLIST (seems like a lot to do, but it's all very valuable and time well spent)
Complete the Pre-Rotation Self-Assessment Learning Test
"Surf" the surgicalcriticalcare.net website
Review the ICU Educational Objectives
Familiarize yourself with the Resident / Student Responsibilities
Read "Shock: An Overview"
Discuss ICU rotation, call schedule, and patient assignments with the Administrative Fellow


DURING YOUR ICU ROTATION

Once on the SCC Service, you will play an active role in the daily care of patients in the ICUs. The SCC Service is a "consultative" service; that is, it assists the primary service in managing the patient while in the critical care area. SCC has no patients of its own and does not accept patients in transfer from other services. The primary service retains the final decision making authority for the patient, although many services will ask SCC to assume the role of "Managing Physician" and make the majority of the "minute-to-minute" patient care decisions. Close communication with the patient's primary service is essential and cannot be overemphasized. It is also important that the ICU Attending and other members of the SCC team are kept aware of all new patient developments and decisions.

Once in the ICU, you will want to arrange an inservice to the bedside patient monitors and cardiac output computers with the ICU Nurse Educator and an inservice to the mechanical ventilators with one of the Lead Respiratory Therapists. You will find them to be an excellent resource in helping you learn to care for the critically ill.

During your rotation, you will want to continually review the educational materials available on surgicalcriticalcare.net. These materials include the Critical Care Lecture Series (a collection of online didactic lectures, handouts, and Powerpoint presentations on key topics in critical care), the Evidence-Based Medicine Guidelines (concise reviews of important patient care issues and disease processes with recommendations for patient decision making based upon the latest medical evidence and literature), and a collection of Useful Resources.

While you are reviewing the surgicalcriticalcare.net website, you may also want to take a look at our version of the "final exam", the Post-Rotation Test. Completion of this test is required to obtain credit for the rotation. The good news is that it is "open book" and you can look at the questions throughout your rotation (if only college and medical school had been this easy!). The purpose of the Post-Rotation Test is to help guide your reading while on the rotation so that you achieve a broad-based learning experience. The Post-Rotation Test is an interactive, online assessment of your ability to evaluate and manage a critically ill patient. The questions are the same ones that you will have addressed daily on dozens of patients during your rotation.

Many residents and medical students rotate through the ICU in order to gain experience in the performance of various invasive procedures. During this rotation you will have the opportunity to become proficient at a wide variety of such procedures including intubation, central venous catheter insertion, pulmonary artery catheter insertion, percutaneous dilatational tracheostomy, and percutaneous endoscopic gastrostomy (PEG) tube placement. In order to document your experience on this rotation, you will maintain an Invasive Procedure List detailing all procedures that you perform while in the ICU. You will find that it is interesting to review this list at the end of your rotation and see what you have accomplished. This list may also be useful in the years to come as you apply for hospital privileges as documentation of procedure proficiency may be necessary. All residents, medical students, and physician's assistant students should complete a Invasive Procedure List, which is available on this website and should be printed and kept up to date at all times. This list must be turned in to the Department of Surgical Education at the conclusion of the rotation.

DURING ROTATION CHECKLIST
Actively participate in the day-to-day care of patients in the ICU
Assume primary responsibility for the critical care management of your assigned patients
Maintain close communication with the ICU Attending, SCC team, nursing, and respiratory therapy staff
Participate in daily bedside teaching as well as didactic conferences
Continue to review the educational materials available on the surgicalcriticalcare.net website
Present a critical care lecture on a topic of your choosing during the rotation
Maintain an Invasive Procedure List(print paper copy using Adobe Acrobat Reader)


POST-ROTATION

Immediately after completing your rotation on the Surgical Critical Care Service, please make sure that you return to this webpage and complete both the online Post-Rotation Test and the Post-Rotation Evaluation. As discussed above, the Post-Rotation Test, presents you with a critically ill patient and asks you to answer a variety of questions intended to demonstrate your understanding and application of the critical care principles taught during the rotation. The Post-Rotation Evaluation allows you to both evaluate the rotation and teaching faculty as well as provide us with your suggestions for improving the rotation. Completion of both the Post-Rotation Test and Post-Rotation Evaluation is mandatory. Failure to complete these requirements will jeopardize your receiving credit for the rotation. Your course evaluation will be returned to your Dean's office, Department Chairperson, or Program Director ONLY when all of these documents have been submitted.

We hope that this rotation stimulates your interest in caring for these fascinating and challenging patients and that you find surgicalcriticalcare.net to be a useful educational resource. We encourage you to come back to surgicalcriticalcare.net frequently as the practice of critical care medicine is constantly changing and these changes will be reflected in the materials you find on this website.

POST-ICU ROTATION CHECKLIST
Complete the Post-Rotation Test
Complete the Post-Rotation Evaluation
Checkout assigned patients to oncoming residents, students
Turn in your Invasive Procedure List


ICU EDUCATIONAL OBJECTIVES

At the conclusion of your rotation through the Surgical ICU's, you will have been exposed to and should feel comfortable discussing the following:

    Cardiovascular
    Hemodynamic assessment
    Oxygen transport
    Preload augmentation
    Afterload optimization
    Contractility enhancement
    Hypertension
    Dysrhythmias
    Shock states
    Resuscitation adequacy
    Preoperative optimization
    Cardiac arrest
    Pulmonary artery catheterization
    Pulmonary
    Oxygen transport balance
    Positive end-expiratory pressure (PEEP)
    Ventilation
    Modes of mechanical ventilatory support
    Pressure support ventilation
    Perioperative physiology
    Airway management
    Oxygen delivery systems
    Intrapulmonary shunt
    Deadspace ventilation
    Acute lung injury (ALI)
    Acute Respiratory Distress Syndrome (ARDS)
    Renal
    Prevention of acute renal failure
    Renal dysfunction/failure
    Low dose dopamine
    Mannitol
    Diuretics
    Hemodialysis
    Continuous Renal Replacement Therapy (CRRT)
    GI / Liver / Pancreas
    Laboratory diagnosis
    Acute hepatic failure
    Acute pancreatitis
    Acute GI bleeding and prophylaxis
    Central Nervous System (CNS)
    CNS injury evaluation and treatment
    Intracranial pressure monitoring
    Reduction of cerebral edema
    Maintenance of cerebral perfusion
    Brain death determination
    Infectious Disease
    Antimicrobial prophylaxis and therapy
    Antifungal prophylaxis and therapy
    Fever evaluation
    Sepsis vs. septic shock
    Bacterial pneumonia
    Bacteremia
    Systemic Inflammatory Response Syndrome (SIRS)
    Pharmacology
    Antibiotics / antifungals
    Vasoactive medications
    Pain management
    GI stress ulceration prophylaxis
    High-dose steroids in spinal cord injury
    Sedation and anxiolysis Renal dysfunction adjustments Deep venous thrombosis prophylaxis
    Nutrition
    Enteral nutrition
    Parenteral nutrition
    Immunodulation
    Protein-calorie malnutrition
    Nutritional assessment
    Metabolic
    Fluid / electrolyte management
    Acid / base management
    Blood product utilization / transfusion
    Acute coagulation disturbances
    Adrenal insufficiency of acute illness
    Biomedical Ethics
    Death and dying
    End-of-life issues
    Withdrawal of support
    Advanced directives
    Organ donation
    Resource Utilization
    Cost containment
    Triage & ICU bed allocation
    Cost-effective healthcare
    Reducing use of unnecessary therapies and testing
 

RESIDENT / MEDICAL STUDENT RESPONSIBILITIES

COMMUNICATION is the single most important factor in making or breaking the function of a critical care team. This communication must be in all directions (i.e. primary team to critical care team, critical care team to primary team, critical care team to nursing team, critical care to respiratory care to nursing and most importantly, critical care team to attending physician). Communication between the ICU residents and the ICU attending must be close at all times.

Emergent ventilator changes may be made only by respiratory therapists, ICU attendings, or senior residents / fellows. When ventilator changes are made by non-respiratory therapists, the date, time and nature of the changes must be documented: 1) by a written order on the order sheet, 2) by documenting the change on the ICU flow sheet, and 3) by communicating directly to the nurse (and directly or indirectly to the respiratory therapist).

RESIDENT RESPONSIBILITIES


MEDICAL STUDENT / PHYSICIAN’S ASSISTANT STUDENT RESPONSIBILITIES



AN OVERVIEW OF THE ICU ROTATION

Orlando Regional Medical Center (ORMC) is a regional tertiary referral center. It is the only Level I Trauma Center in Central Florida and one of only four Burn Units in the State of Florida. The SCC Service manages patients in a variety of critical care areas: Surgical / Trauma ICU (10 beds), Neurosciences ICU (8 beds), Medical ICU (8 beds), and Burn / Trauma ICU (14 beds). The SCC Service also regularly cares for patients in the Post-Anesthetic Care Unit (PACU) and the Emergency Department (ED). At any given time, the SCC Service will be managing an average of 15-25 critically ill patients.

The SCC Service consists of a board-certified surgical intensivist (the "ICU Attending"), two board-eligible/certified surgical critical care fellows, a PGY-2 general surgery resident, a PGY-2 emergency medicine resident, and an ICU pharmacologist. Frequently, medical and/or physician's assistant students will rotate on the SCC service as well. Call is every third to fourth night depending upon the number of residents on the service that month.

The "main event" of a day in the ICU is morning attending walk rounds. All patients must be seen and daily care notes written prior to walk rounds. ICU Rounds start at 8 AM (9 AM on Fridays and 7:30 AM on weekends) and last for 2 - 4 hours. Each patient is presented by their primary resident or student to the entire SCC team (you will typically follow those patients that you admit while on call). Special emphasis is placed on the events of the previous 24 hours including physiologic changes, laboratory and radiographic results as well as the outcome of communication with the primary service and other consultant services. Representatives from Nursing, Pharmacy, Respiratory care, Nutrition, as well as the primary service will each add their pertinent comments and plan for the day. Each patient presentation is followed by a discussion of the case by the ICU attending including the pertinent teaching points. After discussion of alternatives and questions, the plan for the next 24 hours is laid out. It is extremely important that communication is clear at this point and that the on call resident or fellow has a complete understanding of the interventions to be made. The resident/fellow should not try to keep this in his/her memory, but notes should be taken so that specific plans are not forgotten. It is also essential that the other members of the team pay attention to the presentations so that they are aware of the pertinent issues for each patient when they are on call. Rounds are followed by a visit to the X-ray reading room in order to see the chest radiographs obtained on each patient during the previous 24 hours.

Once rounds are completed, any necessary procedures will be performed. Percutaneous tracheostomy and percutaneous endoscopic gastrostomy procedures are typically performed between 10:30 AM and 12:00 PM. Central venous catheter placements and exchanges follow. These may need to be delayed until after the SCC teaching conferences on Tuesday (12:00 to 1:00 PM) and Wednesday (12:00 noon to 1:00 PM). While on the ICU rotation, you will be required to present a critical care topic of your choice at one of the Wednesday noon conferences.

The post-call resident and students are sent home as soon as possible following walk rounds and conference. Those residents and students not on-call will assist the on-call resident in completing any necessary procedures, contacting consultants, checking laboratory and culture results, and updating SWIFTMD. Those residents and students not on-call typically are free to leave by 1 PM leaving the on-call resident and students to care for the patients until the following morning. In general, you will find this to be a very reasonable rotation with regards to work hours.

The on-call resident and students will make "Family Rounds" at 4 PM with the ICU Attending. This time is devoted to the patient's families (who frequently have little direct physician contact) and is used to answer their questions and update them on the patient's progress and x-ray results. The importance of good communication between the physicians and patient families cannot be stressed strongly enough. Being in the operating room most of the day, the primary services are frequently not available to talk with families. The SCC team thus becomes an important source of information and assurance to many families. The nurses will frequently ask you to update the family if they have not seen the primary service recently. It takes but a few minutes, fulfills the family's need to talk with a physician, allows you to get to know the family, and can be very rewarding. Obviously any sensitive issues should be discussed between the family and attending surgeon. If you sense any discomfort with the family's relationship with the primary service or any perceived problems in patient care, these items should be immediately brought to the attention of the patient's primary surgeon.

Following Family Rounds, it is generally a good idea to check in with the ICU Shift Manager to identify potential ICU admissions. While on call, make a point of "checking in" with the ICU Shift Manager every 2-3 hours (and more often if the unit is busy) to find out the latest information on admissions, patients in the Emergency Department (who may become admissions), transfers, and the overall hospital bed status. More often than not, the Surgical ICU's are nearly full with only 1 or 2 potential beds or "admissions slots". Triage of stable patients out of the ICU to accommodate critically ill patients should always be in the back of your mind. Close communication with the ICU Shift Manager is essential and will prevent surprise admissions as well as allow you to budget your time and plan procedures.

Each new admission to the ICU should be "worked up" and a report phoned to the ICU Attending. Be sure to have a treatment plan for discussion.

The on-call resident will make "Checkout Rounds" at 9 PM with the ICU Attending by telephone. This is an opportunity for the resident to have a one-on-one discussion with the attending. Each patient's current vital signs, hemodynamics, and progress (or deterioration) since Family Rounds are discussed. Clarification of plans, potential triage patients, new admissions, and preoperative evaluations are all discussed. No question should remain at the end of the conversation as to the plan of action for the night.

While on-call, you will generally be notified of each admission by one of the residents on the primary service. For each admission, the on-call resident / student should write an admission note with details of the history, reason for admission to the ICU, intraoperative course, intraoperative complications, admission physical examination and results of admission blood work and chest x-ray, assessment and plan. Past Medical History should be obtained from the patient's family (if available). Such a note is of use not only for presentation of the patient to the attending, but as a summary for the incoming team. The note should be concise and limited to no more than two pages.

There is a general order for prioritizing admissions when a bed becomes available. This is detailed in the ICU Bed Allocation Protocol. In brief, unstable patients in the operating room who will require invasive critical care monitoring or pulmonary support always have first priority for admission. Unstable patients from the Emergency Department are the second priority. Unstable patients from the floor or step down units are considered next. Pre-operative cardiopulmonary evaluation patients represent a special group of patients who are given a high priority for admission by virtue of their potential for becoming critically ill postoperatively. Only after the above patients are admitted are the more routine admissions assigned beds. Standardized, pre-printed orders for admission to the ICU are available in the ICU, PACU, Emergency Department, and Progressive Care Unit (PCU). Patients admitted to the ICU are strongly encouraged to have these orders filled out. All admitted patients should have admission orders written or co-signed by a senior resident of the surgical team. These orders include essential clinical information; team beeper information; routine nursing orders for skin care, tubes, monitoring equipment and dressings; intravenous fluids; IV infusions; antibiotics; all other medications and patient care equipment. Mechanical ventilation orders are usually given by the ICU resident. The orders written by the team should be reviewed to make any necessary changes and additions (all changes should be discussed with the senior/chief resident or attending surgeon on the admitting surgical team).

If at any time things are not "going well", problems have developed, or you are not sure how to handle a particular problem, it is best to call the ICU attending and talk it over. It cannot be stressed enough that the ONLY ERROR IS NOT CALLING. Before calling the attending, all the information pertinent to the problem should be collected and tentative and alternative strategies thought out.

If you are the on-call resident and either a percutaneous tracheostomy or PEG tube placement is scheduled for the following day, make sure that a signed consent form is on the chart and that these procedures have been explained to the family by either you or the ICU attending during family rounds. Ensure that the patient's tube feedings are on hold as of 4 AM and that dextrose containing maintenance fluids have been started. Also be sure to call the Endoscopy Suite the afternoon prior to the procedure to schedule the PEG procedure; they will bring an endoscopy cart to the ICU for the procedure.

While on the ICU rotation, you will spend a great deal of time working alongside the ICU nursing and respiratory therapy staff. It cannot be stressed strongly enough that it is vital to work constructively and amicably with the nurses and respiratory therapists. You will find that you learn as much from the ICU nurses and respiratory therapists as you do from the ICU Attendings. Good rapport with the staff will lead to better patient care. The majority of the nursing and respiratory staff are highly trained and experienced possessing sound clinical judgment which should not be discounted. You will depend on them for accurate information, early warning of potential problems, execution of complex orders, and set up and use of the multiple, complex monitoring devices commonly used in the unit today. Many of the nurses and respiratory therapists you encounter in the ICU were practicing critical care before you even considered medical school and will continue to be at ORMC long after you leave! Approaching your time in the ICU with a mind open to learning from the ICU staff will provide you with immeasurable and long lasting benefits.

To know everything about every patient on the service is the challenge of the ICU rotation. The SCC service utilizes a computerized database to facilitate daily patient care. This database, specifically written for the department, is housed on the corporate Intranet or "SWIFTMD". This database contains most of the important information that will help you organize your daily patient care activities including patient demographics, laboratory results, culture results, antibiotics ordered, radiologic studies, medication records, patient transcription, as well as procedure documentation. The database will help you keep track of your patients and log your procedures. If you are unfamiliar with SWIFTMD, you will receive a detailed orientation once you begin the ICU rotation.

A patient is ready to be discharged from the ICU when intensive care is no longer needed or the reason for intensive monitoring either by medical or nursing staff is over. Both the ICU and the surgical team have to reach this conclusion before the actual discharge occurs. Specific transfer criteria and PCU admission criteria are available in the ORMC policy and procedure manual. Sometimes disagreements may arise regarding the fitness of the patient for discharge, or the need for a step-down or intermediate care unit. These disagreements are usually ironed out when the teams have an open discussion of the case either at the fellow/resident level or, if necessary, at the attending level. Patients and families should be prepared for the transfer to the floor or step down unit ("ligation of the umbilical cord") particularly after prolonged ICU stays. If the patient is transferred in the middle of the night, the family should be prepared and notified in advance. Usually the ICU team is more conservative with respect to placing the patient in an intermediate care unit but, ultimately, the surgical team is responsible for the disposition of the patient after discharge from the unit. All discharges and transfers should be reviewed by the ICU attending (NO EXCEPTIONS). Transfer orders must be in the chart before the patient leaves the ICU. It is important to have the surgical team write orders as soon as discharge is agreed upon so there are no delays when the step-down unit or regular ward bed becomes available.


TIPS FOR SURVIVING THE ICU ROTATION