General Duties
Under the direction of the MIS and Intensivist physician staff, the resident on the ICU rotation will do the following for patients assigned to the resident ICU panel:
a. Perform accurate history and physical exams
b. Review and interpret relevant lab and imaging information c. Develop appropriate problem lists, using a comprehensive organ based approach d. Formulate daily evaluation and management plans based on the problem list e. Effectively communicate the above information in daily written progress notes and verbally during rounds. When appropriate, take part in family conference discussions. f. Carry out assigned care tasks including writing orders, doing procedures, calling consultants, etc. in a timely manner.
Under appropriate supervision, participate in procedures as opportunities arise during the rotation, whether in the ICU, the OR, or the ER
Attend all ICU rounds and didactic conferences
Provide appropriate sign out information to covering residents on ICU panel patients.
Keep track of diagnoses seen and procedures done on palm pilot database for reference and guide to focused teaching and reading.
Read and refer to information on relevant ICU topics in the syllabus, teaching modules as well as do independent reading and research as needed to help care for patients.
Present 1 short didactic presentation per week during ICU rounds.
General Structure of Day
6:00 - 7:30 a.m. Pre-round on panel patients
7:30 - 9:15 a.m. Round with MIS Attendings, if time then do intubations with anesthesia
9:15 - 9:45 a.m. Joint ICU rounds (MIS resident team and intensivist)
9:45 — 10:30 a.m. ICU work rounds, finish attending rounds with MIS attendings
10:30 — 11:00 a.m. ICU rounds with intensivist / nursing team
11:00 - 12:00 p.m. Finish ICU, do intubations with anesthesia
12 — 12:30 p.m. IM didactics Mon, Tues, Wed & Fri
12:30 — 1:30 p.m. Lunch conference activities
1:30 — 5:30 p.m. TFM continuity clinic (1/2 day/week) Thursday afternoon block didactics ICU admits, do intubations with anesthesia, reading,etc
Details of Daily Activities
Before 9:15 a.m. the resident will divide their time between completing necessary pre-rounding on assigned patients to their panel, rounding with MIS attendings and checking in with the OR for intubations and line placement with anesthesia.
A. Pre-rounding 6 — 7:30 a.m. — residents will pre-round on ICU patients assigned to the three non-resident MIS panels, reviewing patients known to them from previous days and new patients admitted overnight to the services. New admissions to the service from the night before will be communicated to the resident in the usual fashion by the night call teams.
B. 7:30 — 9:15 a.m. Round with MIS attendings or if low panel count, do Anesthesia procedures in the OR — referring to the list of participating anesthesiologists below, and their monthly schedule for when they are in the OR. the resident will report to the OR at 7:30 a.m. to participate in. Opportunities for intubations and line placements under the direction of one of these attending anesthesiologists will occur at other times during the day, such as 11-12noon and in the afternoon - the resident is expected to pursue these opportunities as well when time and care demands allow.
Participating Anesthesiologists: Baird, Bouterse, Boyer, Donato, Hart, Horn, Lord, Minagawa, Robinson, Rue, Speer, VanderHoven, Wong (* - would try these first)
9:15 — 9:45 a.m: Joint ICU Rounds — the resident is expected to be present at the daily joint ICU rounds with the intensivist and MIS resident team members. Relevant aspects of the cases being followed should be presented here, with specific clinical and educational questions posed to the intensivist. At least weekly, the resident should present a brief evidence based clinical summary or pearl on issues relevant to patients being followed.
9:45 — 10:30 a.m. — ICU work rounds, finish attending rounds with MIS attendings
10 — 10:30 a.m.: ICU Intensivist / Nursing team rounds— the resident is expected to be present at the daily rounds of all patients in the ICU with the intensivist and nursing teams. This is an excellent opportunity to follow the course of ICU illness in multiple patients, with greatest attention to areas pertaining to knowledge and skills listed in the goals and objectives. As time permits, the intensivist may also review interesting x-rays, and answer questions pertaining to the rotation goals and objectives.
11:00 — 12 noon: Finish work rounds— this is time to finish notes or do procedures either in the unit or with anesthesia.
12:00 — 12:30 p.m. — IM didactic lectures on Mon, Tues, Wed, & Fri in 5J conference room.
1:30 — 5:30 p.m. on Unassigned afternoons — time to be filled with variety of activities: new admits, procedures in the unit or with anesthesia, work on reading/teaching modules.
Call / Cross Cover / Weekend Coverage
Call Duties — the resident takes part in the normal inpatient call team rotation of q 4 nights.
Cross Coverage -The ICU resident should provide appropriate sign out information to the covering resident(s) call team during afternoon clinic and for the evenings during the week. For weekends off, patient care reverts to the assigned attending only.
Weekend rounds — the ICU resident will round on the panel when on weekend call as per usual inpatient protocol. When not on weekend call, the attending will round primarily on the panel patients — no resident cross coverage will occur for weekend days that the ICU resident is off.
Other Educational Activities
Family Conferences
When possible residents should participate in all family conferences on their patients. Attention should be paid to the objectives for such conferences listed in the educational objectives. Faculty or other attending physicians present at the conferences should offer feedback on resident performance after the discussion, using the family conference resident feedback form.
Radiology Review
As per daily activity listing, time should be set aside during each day to review relevant and educational x-rays demonstrating conditions listed in the objectives. As time allows, residents should go through the teaching file for the ICU as well.
Readings and Resource Materials
ICU textbook - in resident call room.
ICU resident handbook - given out at start of rotation
For preparation for work in the OR, the chapter on Airway Management (Clinical Anesthesiology, pp. 59-84) is required reading; additional information is available from the OR education coordinator, Theresa Renico-Miller (pager 903-9019) for access to another more complete text: Clinical Anesthesia, 4th edition, Barash, pp. 595-630, Airway Managment.
In addition, you should try to contact Jeff Robinson, one of the TG anesthesiologists before the month starts. He is particularly interested in teaching the residents the principles of airway management, and meeting with him will be worth your trouble. Contact information for him: JRobinson@harbornet.com, or pager 291-0721.
On-line reference materials (Up to Date, etc.) to answer clinical questions about current patients, and to meet the educational objectives listed for the rotation.
- Procedures
During the rotation, the ICU resident should participate in all procedures that arise on their own patients when appropriate. In addition, to insure adequate procedure experience during residency training, when residents are on call, notifying the ER of their availability for ICU appropriate procedures such as central lines, intubations, chest tubes, etc will help insure continuity exposure to these procedures during the course of training. The following is the plan for accomplishment of procedural skills important for this rotation:
Central Lines
i. On assigned ICU patients on panel ii. On other ICU patients with supervision of intensivist/pulmonologist iii. On patients in the OR during time with anesthesia iv. On Surgery trauma patients as opportunities arise v. In ER, on patients being stabilized for transfer to ICU
- Intubation
i. With Anesthesia during assigned times ii. In ER on patients being stabilized for transfer to ICU iii. As occasion arises during codes and in the unit.
- Ventilator Management
i. With assigned panel patients on service ii. As observer during intensivist ICU rounds
- Transthoracic Pacer
i. As occasion arises during codes and in ER ii. As part of teaching rounds at least once during month on service.
- Palm Pilot Check off List
During the rotation, the resident should keep track of the pertinent ICU diagnoses seen and procedures done on their palm pilot database. This will be helpful for future privileging requests and guide the focus for teaching by attendings and reading by the resident.
VI. Patient Panel
- Source of Patients
Primary source are the three MIS non resident panels — the resident will see all MIS patients in the ICU on these two panels up to the panel limit, either doing the primary admission or picking them up in the morning from admissions during the previous night. Primary attending for these patients is the MIS attending for that service, although educational input is also gleaned from intensivist of the week during rounds, as well as from any consulting specialists.
Allenmore ICU patients - the resident should follow patients admitted to the Allenmore ICU service under the Allenmore MIS attending when their Tacoma General panel census drops to one (or when the workload and educational value of 2 patients is felt to be not meeting educational objectives).
Secondary Sources - residents may have the opportunity to follow patients from the following sources if felt appropriate by attending and patient/family.
A. Intensivists — either for patients they are the primary Attending, or for patients they are acting as the consultant. B. Trauma Surgery service — this service would be mainly helpful for involvement of the resident in procedures in the unit. C. Cardiologists/Cardiac Surgery — same as Trauma service
Panel Limits — generally the maximum should run 3 patients - allowing sufficient time to participate in OR procedures and finish rounds in a timely manner.
Admissions to panel — during on duty times during the day, the resident will perform admission history and physical exams on ICU patients being admitted to the MIS non-resident panel services. During off duty times, the on call resident team admits these patients as per the template below, with care passed off to the ICU resident the following morning.
Admissions to the resident ICU panel - who does them :
Basically, when panel is open and ICU resident is available, that resident admits. Otherwise when the panel is open, the call team admits. Panel closed — admits revert to pop off as currently with MIS admissions.
Time of Day
Res Panel Open
Res Panel Full
AM weekday
ICU Resident
Pop off to MIS -
Follow current pop-off rules
Afternoon weekday, no clinic
ICU Resident
Afternoon weekday, in clinic
Call team/Sr. Resident
Evenings, ICU Res. off call
Call team/Sr. Resident
Nights Sunday-Thursday
NF Resident
Weekend - Resident on
ICU Resident
Weekend - Resident off
Call team/Sr. Resident
- Off loading panel patients to make room for new admits — at the mutual agreement of the resident and attending, panel patients can be offloaded back to the attending to make room on the resident panel for new admissions when it is agreed that little educational benefit remains with continued resident contact.
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