ICU Rotation

Upon completion of the ICU rotation, the neurosurgery resident shall be able to:

  1. Describe the physiology of pulmonary gas exchange, and describe the clinical consequences of dead space ventilation and pulmonary shunting.
  2. Discuss working classification of respiratory failure, and list common causes for each classification (e.g. hypoxic-hypercapneic)
  3. Interpret arterial blood gases, including calculation of A-a gradient and identification of acid-base abnormalities (e.g. uncompensated acute metabolic acidosis).
  4. Outline the pathogenesis of acute respiratory distress syndrome, and list its common causes. Describe the Pathology.
  5. List the indications/criteria for intubation/extubation.
  6. Discuss the various types of mechanical ventilation and their indications.
  7. Describe positive pressure ventilation and its interaction with the management of patients with severe closed head injuries (e.g. impaired cerebral venous drainage, permissive hypercapnea causing vasodilation).
  8. Interpret an electrocardiogram, including identification of common dysrhythmias (e.g. atrial fibrillation, ventricular tachycardia).
  9. Identify and initiate treatment for common, acute cardiac events (e.g. myocardial infarction, defibrillation for pulseless ventricular tachycardia).
  10. Describe a working classification for shock, outline the pathophysiology and hemodynamic abnormality for each type (e.g. hypovolemic, septic shock:), and initiate treatment for each type.
  11. Outline the commonly used inotropes, their indications for use, and their pharmacological effects.
  12. Outline the commonly used antihypertensive agents, their indications for use, and their pharmacological effects.
  13. Discuss the indications, benefits and risks of invasive hemodynamic monitoring.
  14. Describe a working approach to acute renal failure, including classification, history, physical examination, investigations (e.g. urinalysis, urinary electrolytes), and initial treatment.
  15. Outline the etiology, pathophysiology, and clinical features of systemic inflammatory response syndrome and multiple organ failure.
  16. Outline the indications for total parenteral nutrition, and become familiar with the nutritional requirements for patients with severe closed head injury.
  17. Manage all aspects and Critical care of increased ICP:
    • Describe the concepts of normal and increased ICP, CPP, CBT and factors which affect change or homeostasis.
    • Describe the metabolic monitoring of increased ICP and the parameters and therapies used to manage it.
    • Describe excitatory neurotoxicity, pathophysiology and the cellular and molecular changes which occur.
    • Describe the therapies and mechanisms and manipulations of CBF, hypertension and ventilation to restore normal brain metabolism.
    • Describe the mechanism, pathophysiology and pharmacology of the following adjuvants to manage increased ICP: hypothermia, hypertension, barbiturates, and free radical scavengers
  18. Perform the following skills:
    • Insert an oropharyngeal/nasopharyngeal airway
    • Perform endotracheal intubation
    • Obtain vascular access, including peripheral venous access, central venous access (femoral, subclavian, internal jugular), and venous cut down
    • Insert a jugular bulb
    • Obtain an arterial line (radial, femoral)
    • Thoracostomy

During the rotation, all residents should fulfill the Royal College’s CanMEDS Competencies.

COMMUNICATOR:

  1. Establish therapeutic relationships with patients and, more significantly, families.
  2. Conduct, document and present appropriate history and exam of a critically ill often unconscious patient.
  3. With appropriate supervision discuss information on ventilator and medical care of a critically ill patient with family.
  4. To gain familiarity with discussions around appropriate level of care in the setting of critically ill patients and end of life situations.
  5. Through observation and performance of relevant ICU consultations,.
  6. To observe and participate in effective communication with patients, families and allied health staff in the context of acute illness, serious morbidity and stressful and emotional situations for patients and families
  7. To understand basic principles of communication with allied health staff and relevant terminology.
  8. To participate in efficient and effective team handovers

COLLABORATOR:

  1. Work/collaborate effectively in an interdisciplinary team, including pharmacy, respirology technicians, nursing personal to manage critical illnesses
  2. Consult other medical services such as endocrinology, and infectious diseases appropriately
  3. Take part in educational activities and teaching available on the ICU service
  4. Be able to share workload and duties appropriately with resident colleagues
  5. To work and collaborate effectively with other members of the of the team, physiatrists, pharmacists and other medical services, allied health staff, patients and families to optimize safe and effective care in the acutely ill patient.

MANAGER:

  1. Effectively utilize, allocate, and prioritize finite resources in context of managing a critically ill patient.
  2. Manage own time, education and personal life for a balanced lifestyle
  3. Work effectively and efficiently, to learn time management skills in the medical setting
  4. Triage patients being able to identify ICU emergencies that require prompt and immediate management.
  5. To understand the process of transferring patients from other centres without ICU care
  6. To understand appropriate indications for referral to services for continuing care outside of ICU setting.

HEALTH ADVOCATE:

  1. To appreciate and respond to determinants of health in critically ill patients
  2. Advocate for timely and appropriate tests/investigations to minimize wait times in critically ill patients.
  3. Contribute to overall patient well-being and outcome
  4. Facilitate return/advancement of patient to care outside of the ICU.
  5. Consider and practice preventative measures for ICU admission though ICU consults/outreach in ill patients on the wards.
  6. Appreciate the barriers for transferring patients to access ICU, from within and outside the hospital.

SCHOLAR:

  1. Participate in rounds and educational activities, residents are expected to be fully involved in all educational activities of the ICU service.
  2. Identify and seek out personal learning needs, particularly in context of neurosurgical patients who need ICU care.
  3. Apply principles of critical appraisal to medical information, be involved in journal club and various rounds.
  4. Facilitate patients, family, student and peer learning
  5. Contribute to development of new knowledge, be actively involved in research projects where appropriate in the ICU, particularly with neurosurgical critical illnesses managed in the ICU.
  6. Apply principles of critical appraisal to medical information
  7. To solidify knowledge of critically ill patients, with special attention to ventilator management and head injury.

PROFESSIONAL:

  1. Demonstrate a commitment to their patients, profession, and society through ethical practice
  2. Exhibit appropriate professional behaviors in practice, including honesty, integrity, commitment, compassion, respect and altruism
  3. Maintain appropriate relations with patients and other health care providers.
  4. Show appropriate respect for opinions of other health care providers
  5. Be able to appraise and identify own limits with respect to knowledge and patient care, and when to ask for assistance and consult effectively