Department of Anesthesiology
Division of Critical Care

Resident Education

Resident Expectations during Critical Care Rotations

The ICU staff intensivists (either anesthesiologist or surgeons) are responsible for the supervision, direction and coordination of clinical activities in the ICU. Patients admitted to the TICU/SICU continue to be under the care of the admitting surgeon/surgical services and there is the possibility for confusion regarding patient management to occur. In order to avoid confusion, all ICU orders other than highly specialized ones such as immunosuppression, specific wound management etc will only be written by the ICU team. It is vital that residents be completely up-to-date on their patients and be able to communicate effectively with surgeons and consultants. It is most important, however, to notify the ICU faculty or critical care fellow of any significant changes in a patient’s condition. It is also our policy to notify the attending surgeon or surgical residents/fellow when any major change in a patient’ status has occurred. Communication is absolutely key, if you have any doubts at all, CALL!!!!!

The ICU attending is present in the ICU on a daily basis and is available at night by phone and pager. This coverage is provided on a weekly basis from Monday to Monday. In the CVC ICU, anesthesiology residents provide the majority of house staff coverage, with rotating cardiology, cardiac anesthesiology and critical care fellows providing some in-house coverage from time to time. Anesthesiology residents provide half the in-house coverage in the SICU with junior and senior surgery residents from a variety of services sharing the other half. Ideally, on-call teams in the SICU comprise an anesthesiology with a surgery resident. Critical Care fellows provide in-house coverage in the SICU and 24/7 beeper coverage in the CVC ICU. ICU Nurse Practitioners and Physician Assistants augment both day time work and night call 24/7 in the CVC ICU.

It is the Critical Care Faculty’s very sincere wish to make your critical care rotations the most rewarding educational experience of your residency. To that end we will do everything we can to provide you with the materials and experiences that will dramatically increase your understanding of and ability to manage critically ill patients. At the same time, it is understood that these rotations will be quite challenging both intellectually as well as physically do to the work required in order to provide exceptional care to these patients. The key to succeeding in this rotation is to work as a team, especially with each other, as well as your faculty, the surgeons, the critical care nurse practitioners, ICU nurses, Respiratory therapists and consultants.

Beginning the ICU Rotations

A. Pre-Rotation

• The critical care coordinator (Ann Nadeau 936-7241) will contact you prior to your rotation to pick up education materials (ICU Orientation packet – this document & CVC ICU protocol Book) and be briefed on ICU expectations and procedures.
• Check the relevant ICU Call schedule {generally created by Chief residents(CVC ICU) or Senior Surgery Resident (SICU) during prior month - SICU call schedule has predetermined Anesthesia and Surgery call days determined for the entire year}
• Visit the ICU prior to your first day on the rotation. Ask one of the current ICU residents or physician extenders {NPs or PAs} to show you around and see how things work

• Stethoscope
• Pen-light
• Pocket pharmacopeia/clinical handbook; Tarascon, Epocrates, Washington Manual, Ferri’s guide, MGH pocket Anesth, Sanford’s guide to antimicrobial therapy
• Note cards or some form of note taking pads/device

• Pick-up your patients from Post-call resident (0645 or 0700 at latest).
• Pre-rounds; evaluate events of previous night, current condition and plans for your patients. Discharge orders for patients scheduled to leave ICU-check with post-call resident.
• Daily note for your patients (0645 to 0800).
• Orientation prior to rounds (0800).
• Morning Rounds {see times for morning rounds below}

D. Daily Schedule   Note: these times are a general outline of the day in either CVC ICU or SICU. The actual times may vary a bit depending on work load and events which are occurring in the ICU.

0645-0800: Pre-rounds; discuss issues with surgical teams during their morning rounds; generate lists of surgery teams’ concerns, plans, and suggestions.
0800-0820: X-ray rounds
0830-1130: Morning work-teaching rounds
1530-Afternoon work rounds
-----Other-----
Tuesday & Thursday 1100-1200: CA-2 & CA-3 Resident tutorials
Tuesday 1130-1230: SICU Critical Care journal club
Wednesday 1130-1300: SICU Core Lecture Series.
Thursday 0700-0800: Anesthesia & Surgery Weekly Grand Rounds.

E. Weekend/Holiday Schedule (post & On-call residents only)
0700-0800 Pre-rounds
0800 X-ray rounds
0815-1100 Work Rounds

• review their patients previous nights’ events with the on call resident.
• pick-up new patients from the on-call resident {check ICU board for resident initials by patient’s name
• review patient’s course with the nurses
• examine patients, record all relevant data from bed-side charts and CareWeb on a daily note sheet or CareWeb Work tool
• formulate a general plan of action
• prepare patients who are ready for discharge {discharge orders}
  
  During daily rounds, the previous day’s admissions are presented and further plans are devised.
  
  Rounds will, in general, take about 3 hours.
  
  The post-call resident is vital to efficient transmission of important clinical information from the previous day and night and therefore is required to be present for morning rounds. Team work is essential to help each other. You will all need each other during this rotation, and helping one another is critical.
  
  There are no set ‘rules’ as to when residents should leave for the day. The post-call residents are the only ones who will leave after morning rounds or ICU Core Lecture. The ICU teams generally create a ‘late resident’ (this may be the pre-call resident if they do not have to be at morning rounds in the am when on call) If the ICU is very busy, all the other residents may stay late to help out, there is no set time for residents to leave. House staff are required to sign-out to the on call resident prior to leaving the hospital for the day. Please check with the On call resident or Attending prior to leaving especially if the ICU census is high or the team is busy, or if post-operative patients are expected in the late afternoon. There is an obvious balance between exposure to patients and events that can happen anytime during the day and just sitting around with nothing to do. Our desire is that you be exposed to as much clinical decision making as you can or use the time during the day to study critical care reading/education material.