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Combined Medical and Cardiac ICUs and Stepdown Unit

Educational Purpose

The Purpose of this rotation is to have the fellows gain experience with the diagnosis and management of patients with critical illnesses as well as those with cardiac diseases in the setting of a closed unit, to gain experience with monitoring and supervision of such a unit, and to gain experience in providing consultations to the physicians responsible for the care of patients in the SICU.

Teaching Methods

Attending Rounds: Bedside teaching; review of mechanical ventilation and weaning modalities, theoretical and practical experience with hemodynamic monitoring, review of diagnostic tests such as chest roentgenograms, computed axial tomograms, radionuclide scans, pulmonary angiograms; discussion and development of a meaningful, practical and cost-effective approach to diagnosis and treatment; interaction and communication with the primary care providers.

Special emphasis is placed on cultural, socioeconomic, ethical, occupational, environmental, as well as behavioral issues by the attending physicians.

The fellows have a very close interaction with the Cardiology attendings and fellows in this combined unit and therefore gain experience with cardiac patients that would not be typically encountered in an MICU.

Procedures: Performed under the supervision of the attending physician whose role gradually evolves to that of a critical observer as the fellow gains experience with establishment of and maintenance of open airway, intubation, invasive and non-invasive mechanical ventilation, liberating the patient from mechanical ventilation; calibration and operation of hemodynamic recording systems; maintenance of circulation; pharmacokinetics and dynamics, use of paralytic agents; insertion of central venous, arterial and pulmonary artery flotation catheters; transcutaneous tracheostomy; basic and advanced cardiopulmonary resuscitation; parenteral nutrition.

Pathology: The fellows are expected to review the results of diagnostic studies that include bronchoalveolar, pleural fluid and tissue, and lung tissue specimens, with their attending physician and the pathology attending. Fellows are expected to review all deaths in detail. This includes obtaining and participating in the autopsy and questioning all aspects of the management of the case.

Case Conference: Diagnostic and therapeutic approach to pulmonary and critical care patients are discussed in detail along with the relevant literature on a weekly basis.

Disease Oriented Clinical Conference: Pulmonary, Critical Care, and Sleep Medicine diseases are covered in this weekly conference.

Principles of Practical Pulmonary Conference: Topics not identifiable as belonging a disease are covered in these weekly sessions. Subject matter includes physiology, procedures, and interpretations of tests.

Mix of Diseases, Patient Characteristics, and Types of Clinical Procedures and Services

The patient population encountered in this unit is relatively older and they present with neurologic (cerebrovascular accidents, seizures, meningitis), cardiac (myocardial infarctions, unstable angina, heart failure, cardiac arrhythmias), respiratory (acute and chronic hypoxic or hypercapnic respiratory failure), renal (acute tubular necrosis), metabolic (diabetic ketoacidosis, electrolyte disturbances), hepatic (encephalopathy), and gastrointestinal (bleeding) disturbances.

The role of the fellow in this closed unit is that of a junior attending physician. The fellows provide consultation to the physicians responsible for patients in the CCU and SICU setting.

Fellow Evaluation Method

Fellows are evaluated by the attending physician who supervises them over the duration of the rotation. Verbal feedback is given is given on an ongoing basis. An ABIM-format evaluation is completed and reviewed with the fellow at the completion of the rotation. If an attending physician judges that a fellow is not performing adequately in any area of evaluation, he or she must explicitly provide constructive feedback sometime during the middle of the rotation.

Fellows in return, evaluate their attending physicians and the rotation in terms of patient mix, experience as well as the number of procedures by filling in an evaluation form at the end of the rotation.