M4 Surgery Critical Care Selectives

Critical Care Selective Objectives and Graduation Competencies:

Critical care selectives will provide exposure to a number of core symptom complexes considered crucial to the management of the patient with critical illness.

Core Critical Care Principles:

The student will be able to discuss the core principles of critical care management including, DVT and stress ulcer prophylaxis, nutrition, pressure wound and skin care, delirium, sedation and pain management as they pertain to each critical sub-specialty. (PC4, PC5)

Organ System Compromise:

Develop an integrated approach to evaluating and discussing the patient with either single or multi-organ compromise, including but not limited to cardiac, renal, gastrointestinal, pulmonary, neurologic, infectious and hematologic. Describe how each system functions independently or dependently of each other in regards to the specific critical illness. (SBP2)

Respiratory Dysfunction:

Recognize patients with respiratory distress, manifested as an inability to either oxygenate or to ventilate and discuss etiologies of respiratory failure based on different patient populations. The student should exhibit a general understanding of invasive and noninvasive means of mechanical ventilation.

Hemodynamic Compromise:

Manage patients with hemodynamic instability admitted for monitoring and treatment of arrhythmias, hypotension or hypertension. Describe the different types of shock states including cardiogenic, distributive (septic) and hypovolemic and discuss the importance of maintaining the physiologic balance of oxygenation and tissue perfusion in caring for these patients.

Metabolic Compromise:

Recognize and discuss management of patients with complications of renal failure including acid-base imbalance, volume overload and electrolyte abnormalities.

Palliative Care:

Evaluate the critically ill patient in regards to terminal illness and end-of-life issues. The student will be exposed to family meetings that will deal directly with palliative care issues.

Critical Care Course Objectives:

Patient Care - Students are expected to achieve the knowledge, skills, attitudes and behaviors to enable them under supervision to demonstrate increasing clinical capabilities as they progress toward residency, specifically to:

• Performs an efficient and focused comprehensive history and physical exam and presents an appropriate plan of care for critically ill patients. (PC1, PC2, PC3, PC6)
• Observe and participate in procedural opportunities pertinent to each selective such as central and arterial line placement and endotracheal intubation. (PC6)
• Act at a resident level when assuming care for new admissions, writing orders and discussing cases directly with fellows and attendings. ( PC2, PC4)

Medical Knowledge:

Students will be able to use an appropriate fund of knowledge of current and evolving concepts and practices in critical care.

• Select and interpret pertinent clinical information including radiographic, pharmacologic and laboratory data. (MK1)
• Appropriately use documentation, protocols, data storage and retrieval pertaining to each critical care sub-specialty and the electronic medical record (O2) (MK1)
• Attend weekly didactic conferences and patient-based learning experiences specific to the sub-specialty critical care selective.
• Participate in clinical skills assessments and simulated patient encounters. (MK3)

Practice-Based Learning/Improvement:

Students should demonstrate critical and analytic thinking, awareness of the limitations of their knowledge and skills, and commitment to continuous learning and development. (PBL2, PBL4)

• Demonstrate the integration of evidence-based medicine and similar strategies into solving clinical problems. (MK1, MK2, MK3, PBL1)
• Use electronic medical record and other information technology to support clinical practice and personal education. (MK1, MK2, MK3)
• Use analysis of experiences to improve performance and continuously update personal clinical knowledge and skills. (MK1, MK2, MK3, PBL2, PBL3, PBL4, SBP4)

Interpersonal and Communication Skills:

The care of the critically ill patient is complex and multidisciplinary. It is important that students refine their ability to display interpersonal and communication skills that result in effective information exchange and teaming with patients, their families and other health professionals in a concise, accurate and respectful manner. (ICS1, ICS2, ICS3, ICS4)

Professionalism:

It is important that those caring for critically ill patients integrate the concepts of altruism, accountability, excellence, duty, service, honor, integrity and respect for others into all aspects of their care. (P1, P2, P3, P4)

• Understand informed consent and patient confidentiality. (ICS4)
• Discuss the importance of a culturally sensitive, patient and family centered approach to care, which integrates the emotional and spiritual needs of the patient and family, especially in relation to serious progressive illness or end of life. (ICS1, ICS2, P2, P4)

System-Based Practice:

Students will be prepared to function effectively in teams and within organizational structures. They will demonstrate the ability to call on system resources to provide optimal care. (SBP1, SBP3, SBP5)

Critical Care Selective Course Objectives:

Recognize and intervene appropriately in common medical and surgical crises:

Medical Crises:

1. Respiratory failure (hypoxic and hypercarbic)
2. Hemodynamic compromise {arrhythmias, shock [hypovolemic, loss of vascular resistance (ex: septic), cardiogenic] hypertensive crisis}
3. Electrolyte and acid/base emergencies

Neurologic Crises:

1. Coma, seizure, mental status changes

Surgical Crises:

1. Hemorrhagic Shock
2. Burn resuscitation

Skills acquired during the critical care selective should include:

• Appropriate determination of patient admission and discharge criteria for ICU level care
• Acquisition and interpretation of basic laboratory, radiologic and hemodynamic monitoring data required during medical/surgical crises
• Fundamental familiarity with central and peripheral intravenous access, art4rial lines and Swan-Ganz catheters
• Initiate basic airway management and mechanical ventilation modalities

Simulation Objectives

The Objective: This course was designed to ensure that all students in the selective have the opportunity to practice directing the initial management of an acutely decompensating patient before internship begins. Our hope is that this experience will not only serve as a review of some of the underlying pathophysiology, but also as an opportunity to begin to get comfortable in the role of decision maker.

The Environment: You will be providing care in a patient room of a general hospital ward. You will find a standard hospital bed, a patient monitor with a blood pressure cuff and pulse oximeter. In order to cycle the blood pressure, you will need to press 'start' on the monitor. There are also various oxygen devices as well as a crash cart and defibrillator available should you need them.

The Patient: The computer-controlled mannequin is equipped to demonstrate pupil reactivity, breath sounds, heart sounds, and palpable pulses as well as to carry on a conversation with you. The patient has a PICC line in place should you need IV access.

The Care Team: You will be serving as the physician on call covering our patient. There will be an actor in the room who will play the role of the patient's primary nurse. He/she can also provide the services usually performed by the respiratory therapist (pulmonary medications, oxygen delivery devices...). Our actors do their best to stay in character during the scenario, and ask that you do the same.

Patient History and Testing: The primary nurse for the patient will provide you with the patient's history. If you would like to order laboratory tests, EKGs, or radiology exams, you can give the verbal order to the nurse and she will provide you with results once they are available.

The Confidentiality Pledge: We are all here to learn in hopes of providing better care for our future patients. We know that it can feel awkward to work in this artificial environment. We also know that despite our best efforts to make the scenarios realistic, there are many things that are different from 'real-life' and those things may interfere with your ability to care for our patient as you normally would. Nonetheless, please do your best to buy-in to the experience. In order to encourage participation without reservation, we pledge that all information regarding the performance of specific individuals and scenarios will be kept confidential, and ask that you do the same.

Link to: Simulation Based Critical Care Curriculum and LCME Accreditation Standards