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Surgical Critical Care
Residency Handbook
2007-2008
Department of Surgical Education
Orlando Regional Medical Center
2
"THE TEN COMMANDMENTS"
"Honesty first, last, and always."

"The smart man admits when he is wrong"
"Do it now."

If the unit becomes busy, there may not be time later.

Sleep always comes last.
"Do it right the first time."

The patient will likely not give you a second chance.
"If you don't know, ask."

There is no such thing as a "stupid question”.

You are here to learn. The majority of your critical care education will be
through one-on-one discussions with the ICU faculty.
"Communicate before, not after."

You can be faulted only if you don't call.
"Do it yourself."

Trust no one and assume nothing.

Always see test results or x-rays yourself.

Delegate with discretion.
"Round frequently."
 Anticipate disasters by knowing your patients and identifying untoward
physiologic events before they happen.
"Write it down."

Keep a list of tasks and constantly revise and update it throughout the day.
"Read everyday."

Read about the diagnosis and management of each of your patients.
"Remember the patient and their family."

Keep in mind that it is a privilege to care for each patient AND their family.

Communication is essential.
1
This Fellow’s Manual has been continually revised over the past three decades by countless
fellows from the University of Miami, Vanderbilt University, and Orlando Regional Medical Center.
During your fellowship, you will want to refer to this manual often, mark it up liberally, and take
note of changes that you believe are necessary to improve the manual for future fellows.
TABLE OF CONTENTS
I.
Introduction – Mission Statement
2
II.
Definitions
3
III.
Program Philosophy and Overview
4
IV.
Goals and Objectives
5
V.
Resident Responsibilities
14
VI.
Joining the Surgical Critical Care Team: A Day in the Life
16
VII.
Resident Evaluation and the Core Competencies
23
VIII. Didactic Teaching Conferences
34
IX.
Supervision & Decision Making Authority:
Relation to Faculty, Residents, Medical Students
39
X.
Scholarly Environment
41
XI.
Quality Assurance
41
XII.
Resident Duty Hours and Working Environment
41
XIII. Grievance Procedure
42
XIV. Monitoring Resident Stress and Fatigue
42
2
I. INTRODUCTION - MISSION STATEMENT
The Surgical Critical Care residency program at Orlando Regional Medical Center (ORMC) is an
American Council for Graduate Medical Education (ACGME) accredited 12-month residency
program that is intended to prepare graduates for a career in either academic or private practice
surgical critical care. Following completion of the program, the surgeon will be eligible to sit for
the American Board of Surgery examination certifying "Added Qualifications in Surgical Critical
Care".
The educational philosophy of the program is to provide a comprehensive matrix upon which to:
1) Develop a scientifically sound, evidence-based medicine approach to cost-effective
management of the critically ill patient using the latest technologies and innovations,
2) Facilitate interpersonal skills in physician-patient and physician-family communication
especially with regards to end-of-life and other ethical issues,
3) Promote effective and productive teaching abilities,
4) Encourage and develop intensive care unit leadership and hospital administrative skills,
and
5) Foster an interest in and aptitude for scientific research, statistics, and critical thinking.
Although the term "SCC fellow" is commonly used in day-to-day practice, it must be remembered
that for the purposes of the ACGME and the Residency Review Committee (RRC), the SCC
program is actually a postgraduate "residency" and the terms "fellow” and “resident" may be used
interchangeably. Each resident is trained according to the guidelines set forth by the Society of
Critical Care Medicine to ensure a comprehensive exposure to all aspects of critical care practice
(Guidelines for Advanced Training for Physicians in Critical Care, Crit Care Med 1997; 25:16011607). Our ultimate goal is to fully prepare our graduates to be not only superb clinicians, but
also excellent academic teachers and thought leaders in their future institutions.
The Surgical Critical Care (SCC) Residency is based at ORMC, the 517-bed flagship hospital of a
six-hospital not-for-profit comprehensive healthcare system ("Orlando Regional Healthcare") that
serves the needs of patients throughout Central Florida as well as millions of tourists each year.
ORMC has served as the regional Level I trauma center and burn center for over 20 years and
currently provides trauma care for 22 different counties. With the Arnold Palmer Children's
Hospital, Winnie Palmer Hospital for Women and Babies, and Charles Lewis / MD Anderson
Cancer Center, ORMC serves as a state-of-the-art tertiary referral center providing Central
Florida with a full range of medical services.
This "Fellow's Manual" is intended to provide you with a comprehensive discussion of the SCC
program as well as a brief introduction to the patient care protocols and day-to-day workings of
the intensive care units (ICU) at ORMC. This manual is being constantly revised and updated as
protocols, therapies, and technologies change. As your SCC residency concludes, your
suggestions and additions to the Fellow's Manual will be incorporated. Please read this manual
closely prior to beginning your time at ORMC and review it frequently as your residency
progresses, taking the time to note changes that you believe are necessary to further improve the
manual for future fellows.
3
II. DEFINITIONS
For the purpose of this manual, the following definitions and abbreviations apply:

Surgical Critical Care (SCC) Service – the clinical patient care team providing 24 hour per
day service in the ICU and operating within the SCC residency program. This team generally
consists of a SCC attending surgeon, two SCC residents, a general surgery resident from the
Department of Surgical Education, and a resident from the Department of Emergency
Medicine. During several months of the year, visiting students from various medical schools
may also rotate on the service.

Surgical Critical Care (SCC) Program – the educational program within the Department of
Surgical Education. The program consists of the program director, five full-time surgical
faculty, the research manager, the residency coordinator, and other support staff.

Surgical Critical Care (SCC) Resident – the resident engaged in advanced training for 12
months who intends to become eligible for examination for the “Certificate of Added
Qualifications in Surgical Critical Care” from the American Board of Surgery.

Rotating residents – all residents from the primary general surgery program or other
programs who spend one to two months on the SCC Service.

Chief Resident – the general surgery resident in his/her final year of training.

Admitting physician – the medical staff physician who admits the patient to the hospital.

Primary surgical attending – the primary surgeon responsible for admitting and/or operating
upon a patient admitted to the ICU and consulting the SCC service for assistance with patient
management.

Critical care attending – the consulting surgeon with added qualifications in Surgical Critical
Care who is responsible for the daily operation of the SCC service.

Consulting physician – the physician requested by the attending physician or ICU
managing physician to recommend treatment or diagnostic alternatives while the patient is in
the ICU.

Intensivist – a critical care physician who is board certified within his/her specialty in the field
of critical care.

ICU Managing physician – the physician responsible for management decisions while the
patient is in the ICU. The managing physician is the attending physician unless there is a
written order in the patient’s medical record designating a managing physician or an order
consulting a critical care service for comprehensive patient management.

Intensive Care Unit (ICU) – the critical care units in which the SCC service cares for
patients. This includes the Trauma ICU (TICU), the Neurosciences ICU (NSICU), Surgical
ICU (SICU), the Medical ICU (MICU), and, at times, the Post-Anesthesia Recovery Unit
(PACU), the Trauma Step-Down Unit, the Intermediate Critical Care Unit (ICCU), and the
Emergency Department (ED).

Orlando Regional Healthcare (ORH) – the not-for-profit corporation owning Orlando
Regional Medical Center (ORMC), Arnold Palmer Hospital for Children (APH), Winnie Palmer
Hospital for Women and Babies (WPH), and other hospitals and care centers which are not
part of the educational program.

All references in this document are intended to be gender non-specific.
4
III. PROGRAM PHILOSOPHY AND OVERVIEW
While the care of the most severely ill or injured patient requires the cooperation of multiple
specialties and disciplines, surgeons with advanced knowledge and training are the vital central
element. The goal of this residency is to provide an intensive one-year experience in SCC which
will train surgeons to assume a leadership role in the care of critically ill patients and be prepared
to assume an administrative role in managing a busy surgical or trauma ICU. The specific goals
in this regard are to obtain experience in the multidisciplinary care of sick surgical patients and to
have exposure to all elements of the domain of critical care knowledge and related procedures.
The educational philosophy is to teach not only the individual basics of care of sick surgical
patients, but also the integration of care involving multiple practitioners within the interdisciplinary
process. Philosophically, the ORMC ICUs are “open” units in which any medical staff physician
may admit patients for critical care management. By hospital policy, however, a managing
intensivist must be consulted for each patient admitted. Each admitting physician and primary
surgeon will determine the degree to which they wish to be involved in the care of their patient
while in the ICU. Effective communication and interaction between intensivist and primary
physician is a skill that each SCC resident must develop and master if they are to be successful
in their future career.
The initial year of the residency focuses on gaining advanced skills and knowledge in clinical
aspects of patient care and the basics of surgical intensive care administration. Candidates
desiring to pursue a career in trauma surgery may participate in an optional second year of
training which will offer the opportunity to focus on the development of skills in trauma surgery
and trauma administration while continuing to participate in critical care management.
The SCC resident will be directly involved in all phases of the care of critically ill surgical patients.
The focus of the clinical experience will center around the combined ORMC ICUs. These units
admit a variety of patients from different surgical subspecialties including general, trauma,
orthopedic, vascular, neurosurgical, urologic, and gynecologic surgery.
The SCC residency includes 10 to 12 months in the ICUs at ORMC. The resident may elect to
take up to 2 months of elective rotations including the Pediatric ICU at the Arnold Palmer Hospital
Children, the Nutritional Support Service, the Burn Service, or dedicated time in clinical research
in critical care. Plans to pursue such rotations must be discussed with the program director at the
beginning of the year. The resident will receive 3 weeks of vacation during his/her residency.
Didactic teaching is accomplished through a number of specific conferences. These include: 1)
daily morning bedside rounds; 2) daily afternoon Family Rounds; 3) daily evening checkout
telephone rounds; 4) Fellow’s Conference (Tuesday noon); 5) Critical Care Teaching Conference
(Wednesday noon); 6) Surgical Grand Rounds (Friday morning); and 7) Surgical Morbidity and
Mortality Conference (Friday morning). Residents will be expected to attend and actively
participate in all department conferences. Specifically, they will present complex cases at
Surgical Morbidity and Mortality Conference and be prepared to contribute to the discussion of
cases presented by other surgeons in which they were involved. The SCC residents are
responsible for medical student and junior resident education through daily bedside rounds and
direct supervision of care. Each SCC resident is responsible for at least one Surgical Grand
Rounds presentation each year. The SCC residents will participate as instructors in the
Advanced Trauma Life Support (ATLS) and Fundamental Critical Care Support (FCCS) courses
taught at ORMC.
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IV: GOALS AND OBJECTIVES
The specific educational goals of the SCC postgraduate residency program are to prepare the
resident to apply, evaluate, and teach the fundamentals of surgical critical care and to:
1) Become proficient in critical care knowledge in the following areas:
a) Cardiothoracic-respiratory resuscitation
b) Physiology, pathophysiology, diagnosis, and therapy of disorders of the cardiovascular,
respiratory, gastrointestinal, genitourinary, neurologic, endocrine, musculoskeletal, and
immune systems as well as of infectious diseases
c) Metabolic, nutritional, and endocrine effects of critical illness
d) Hematologic and coagulation disorders
e) Critical obstetric and gynecologic disorders
f) Trauma, thermal, electrical, radiation, inhalation and immersion injuries
g) Monitoring and medical instrumentation
h) Pharmacokinetics and dynamics of drug metabolism and excretion in critical illness
i) Ethical and legal aspects of surgical critical care
j) Principles and techniques of administration and management
k) Biostatistics and experimental design
2) Become proficient in critical care skills in the following areas:
a) Respiratory: airway management including endoscopy and management of respiratory
systems
b) Circulatory: invasive and non-invasive monitoring techniques, including pulmonary artery
catheterization, pulse contour waveform analysis, mixed venous oximetry, application of
transthoracic and transvenous pacemakers, and electrocardiography
c) Neurological: the performance of complete neurological examinations; use of intracranial
pressure monitoring techniques; application of hypothermia in the management of
cerebral trauma; performance of apnea testing for brain death determination
d) Renal: the evaluation of renal function, peritoneal dialysis and hemofiltration, knowledge
of the indications of complications of hemodialysis
e) Gastrointestinal: utilization of gastrointestinal intubation and endoscopic techniques in the
management of the critically ill patient; management of stomas, fistulas, and
percutaneous catheter devices
f) Hematologic: application of autotransfusion, assessment of coagulation status,
appropriate use of component therapy
g) Infectious Disease: classification of infections and application of isolation techniques,
pharmacokinetics, drug interactions, and management of antibiotic therapy during organ
failure, nosocomial infections
h) Nutritional: application of parenteral and enteral nutrition, monitoring and assessing
metabolism and nutrition
i) Monitoring/bioengineering: use and calibration of transducers, amplifiers, and recorders
j) Miscellaneous: use of special beds for specific injuries; employment of traction and
fixation devices
The expected time course for achievement of the education goals outlined above is:





Orientation to patient care and communication protocols
Development of initial critical care knowledgebase and skill set
Refinement of critical care knowledgebase and skill set
Refinement of teaching skills
Development of administrative skills
July-September
July-January
January-March
April-June
January-June
6
Educational resources to achieve these goals are available through the various department
teaching conferences (including the “Fellow’s Conferences” and ”Critical Care Teaching
Conferences”
as
well
as
the
department’s
dedicated
educational
website
(www.surgicalcriticalcare.net). Each SCC resident, under the guidance of the SCC faculty, is
encouraged to review the medical literature and choose the textbook or combination of textbooks
that best suits their educational needs and preferences to augment the above resources.
Details of Goals and Objectives - Core Clinical Knowledge Base
Cardiothoracic-respiratory resuscitation
Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based
Medicine Conference, Critical Care Grand Rounds, Research Conference,
Fundamental Critical Care Support course..
Summary: Residents are exposed to cardiothoracic-respiratory resuscitation on a daily
basis through both bedside teaching and didactic lectures. A primary area of
research within the department is the testing of new hemodynamic monitoring
technologies which will further enhance their understanding. In addition, they
will maintain ACLS and BLS skills, and receive training in Fundamental Critical
Care Support (FCCS).
Physiology, pathophysiology, diagnosis, and therapy of disorders of the cardiovascular,
respiratory, gastrointestinal, genitourinary, neurologic, endocrine, musculoskeletal, and immune
systems as well as of infectious diseases
Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based
Medicine Conference, Critical Care Grand Rounds, Research Conference,
Fundamental Critical Care Support course.
Summary: All topics are covered when encountered in the ICU during direct patient care
and discussed extensively on daily teaching rounds. The ICU faculty are
experienced and well qualified in these areas of knowledge; additional
specialty support is obtained through interaction with consultants and
attendings from other surgical services, including infectious disease,
orthopedics, and neurosurgery.
Metabolic, nutritional, and endocrine effects of critical illness
Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based
Medicine Conference, Critical Care Grand Rounds, Research Conference.
Summary: This aspect of critical care will be acquired through daily interaction with
critical care faculty, supplementary reading, and formal lecture material. The
metabolic and nutritional care of surgical patients is both a fundamental
component of treatment at ORMC as well as a focus of ongoing research.
The discussion of metabolism, appropriate feeding of patients, and the use of
enteral feeding to prevent complications is part of routine daily care. The
presence of both a doctor of pharmacy and a registered dietician on daily ICU
rounds further enhances the teaching in these areas.
Hematologic and coagulation disorders
Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based
Medicine Conference, Critical Care Grand Rounds.
Summary: The majority of hematologic and coagulation disorders will be covered by the
critical care faculty with participation from hematology consulting attendings in
unusual cases. The format includes daily clinical interactions over patients
who have developed specific coagulation disorders as well as didactic
material and evidence-based medicine guidelines. Component blood therapy
is discussed in a dedicated lecture on fluid resuscitation.
7
Critical obstetric and gynecologic disorders
Exposure: Daily ICU rounds; Critical Care Teaching Conference; Critical Care Grand
Rounds, Fundamental Critical Care Support course.
Summary: The SCC resident will be involved in the care of critically ill patients from the
OB/GYN service. These patients are managed primarily by the SCC service
with the OB/GYN attending and resident staff providing specialty-specific input
as needed. Clinical material will be supplemented with reading and lecture
topics.
Trauma, thermal, electrical, radiation, inhalation and immersion injuries.
Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based
Medicine Conference, Critical Care Grand Rounds; Trauma Grand Rounds,
Fundamental Critical Care Support course
Summary: The SCC residents participate extensively in the management of patients
admitted to ORMC’s Level I trauma center. All of the SCC faculty have a
strong dedication to the care of the trauma patient. Trauma care represents a
major focus of attention within the department’s research activities. The burn
unit is also quite busy serving a large region of Florida. An elective rotation on
the ORMC Burn Service is popular among the SCC residents due to both the
operative experience and the professional development / employment
preparation it provides.
Monitoring and medical instrumentation.
Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based
Medicine Conference, Critical Care Grand Rounds.
Summary: There is a vast clinical experience among the faculty in the use of clinical
monitoring devices including all components of hemodynamic, intracranial
pressure, intra-abdominal pressure, and respiratory monitoring. The majority
of ICU patients are monitored invasively and provide a basis for this
experience.
Critical pediatric surgical conditions.
Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based
Medicine Conference, Critical Care Grand Rounds, Fundamental Critical Care
Support course.
Summary: The SCC resident will be involved in the care of pediatric patients who present
to the ORMC Emergency Department and who require critical care
management, but are too ill to be transferred to the ICU at APH. Such care
will be under the direction of the SCC faculty with specialty-specific input from
the pediatric surgeons as needed.
Pharmacokinetics and dynamics of drug metabolism and excretion in critical illness
Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based
Medicine Conference, Critical Care Grand Rounds.
Summary: The SCC Service has an active clinical pharmacy presence on daily ICU
rounds. Residents will interact on a daily basis with a critical care-trained
doctor of pharmacy as well as in lecture settings at various points during the
year. Pharmacokinetics are measured and residents are exposed to the
techniques and mathematics of drug monitoring and drug calculations. In
addition, active discussion of drug metabolism and excretion is discussed on
daily rounds as the pharmacist is part of the multidisciplinary daily rounding
team.
8
Ethical and legal aspects of surgical critical care
Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based
Medicine Conference, Critical Care Grand Rounds, Professional Development
Conference, Fundamental Critical Care Support course.
Summary: Attendings on the SCC service are deeply involved in both the ethical and
legal issues surrounding the care of critically ill patients. One faculty member
currently serves on the Hospital Ethics Committee and interactions with faculty
will be supplemented by reading material and teaching conferences. The
residents are expected to participate in all case referrals to the Ethics
Committee and participate in this important process.
Principles and techniques of administration and management
Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based
Medicine Conference, Critical Care Grand Rounds, Professional Development
Conference.
Summary: Active effort is made to involve the residents in the daily administration of the
ICU with an eye toward preparing them for a leadership role during their future
career. The residents will work closely with the nursing and various ICU
support services and with the program director (the medical director of the
ICU) to learn the principles of ICU and hospital administration. The residents
participate actively in the ORMC and ORH Critical Care Committee meetings
which function to fulfill administrative and quality assurance issues. Residents
also participate in the evaluation of outcomes and the process of continuing
quality improvement within the ICU and are actively involved in the
development of evidence-based medicine guidelines and guideline-derived
outcome measures. The residents are actively involved in the ongoing
structure and content of the educational program as well, and are actively
involved in changing this to suit their individual needs.
Biostatistics and experimental design
Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based
Medicine Conference, Critical Care Grand Rounds, Professional Development
Conference, Research Conference.
Summary: SCC residents are strongly encouraged to become involved in both ongoing
clinical research projects as well as research projects of their own design.
Core lectures in biostatistics, study design, data interpretation, database
analysis, and scientific publication are provided during the Research
Conferences. Residents are required to complete the National Institutes of
Health online training program for new investigators.
Details of Goals and Objectives - Core Basic Science Knowledge Base
A thorough understanding of the relevant physiology and pathophysiology of each disease
process encountered in the ICU setting is essential in order to provide effective critical care
management. As a result, we strive to integrate a thorough discussion of the pertinent basic
science issues within each of the clinical didactic conferences as well as during daily bedside
teaching rounds. This emphasizes the importance of pathophysiology in daily bedside patient
care and promotes a comprehensive approach to evidence-based patient management.
At the start of the academic year, the SCC residents attend an intensive introductory lecture
series that covers the essential basic science issues pertinent to cardiopulmonary support and
shock resuscitation, the foundation of critical care management. As the year progresses, a
thorough range of critical care topics are covered, each lecture incorporating both the relevant
basic science and clinical care issues. The 12-month long didactic curriculum described below
ensures that each SCC resident receives a thorough basic science education.
9
Cardiac
Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based
Medicine Conference, Critical Care Grand Rounds, Research Conference,
Fundamental Critical Care Support course.
Content:
Measured and calculated hemodynamic variables, measured and calculated
oxygen transport variables, intravascular pressures, preload assessment and
augmentation, contractility, afterload support and reduction, oxygen
transport, vasoactive medications and their pharmacokinetics/receptors,
cardiac rhythm and conduction disturbances, myocardial ischemia, valvular
abnormalities, sepsis-induced myocardial depression and regional
malperfusion, various shock states (hypovolemic, hemorrhagic, obstructive,
distributive, endocrine).
Recommended reading: www.surgicalcriticalcare.net and Irwin and Rippe’s Textbook of
Critical Care
Pulmonary
Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based
Medicine Conference, Critical Care Grand Rounds, Research Conference,
Fundamental Critical Care Support course, Ventilator workshop.
Content:
Pulmonary volumes (tidal volume, residual volume, inspiratory volume,
expiratory volume), lung capacities (total lung capacity, functional residual
capacity, inspiratory capacity, expiratory capacity), dead space ventilation,
intrapulmonary shunt, alveolar collapse and recruitment, surfactant
deficiencies, pulmonary edema, pressure-volume relationships, oxygen
delivery and consumption, bronchopulmonary blood flow, acute respiratory
failure / acute lung injury, pulmonary mechanics and gas exchange,
barotrauma / volutrauma, respiratory monitoring (airway pressure,
intrathoracic pressure, tidal volume, pulse oximetry, dead space-tidal volume
ratio, compliance, resistance, capnography), metabolic monitoring (oxygen
consumption, carbon dioxide production, respiratory quotient)
Recommended reading: www.surgicalcriticalcare.net , Irwin and Rippe’s Textbook of
Critical Care, J.B. West’s “Pulmonary Physiology” and “Pulmonary
Pathophysiology”
Gastrointestinal
Exposure: Daily ICU rounds (in collaboration with the Nutritional Support Team); Critical
Care Teaching Conference; Evidence-Based Medicine Conference, Critical
Care Grand Rounds, Research Conference.
Content:
Gastric and intestinal motility/absorption/malabsorption, stress ulceration and
prophylaxis, mucosal integrity and bacterial translocation, intramucosal pH,
acute/chronic
pancreatitis,
nutritional
support
and
assessment,
enterocutaneous fistula pathophysiology and management, intra-abdominal
hypertension, regional malperfusion, thrombotic/embolic disease.
Recommended reading: www.surgicalcriticalcare.net and Irwin and Rippe’s Textbook of
Critical Care.
Renal
Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based
Medicine Conference, Critical Care Grand Rounds, Research Conference.
Content:
Fluid and electrolyte balance, prerenal, intrarenal, postrenal acute failure;
acid-base disorders, creatinine clearance, electrolyte abnormalities,
pharmacokinetics and dynamics of drug metabolism and excretion in critical
illness, acute tubular necrosis, renal tubular acidosis, chronic renal
insufficiency, medication-induced renal insufficiency, interpretation of urinary
electrolytes, rhabdomyolysis.
10
Recommended reading: www.surgicalcriticalcare.net and Irwin and Rippe’s Textbook of
Critical Care.
Hepatic
Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based
Medicine Conference, Critical Care Grand Rounds, Research Conference.
Content:
Cirrhosis, cholestasis, hepatitis, albumin, acute hepatobiliary dysfunction,
pharmacokinetics and dynamics of drug metabolism and excretion in critical
illness.
Recommended reading: Irwin and Rippe’s Textbook of Critical Care.
Neurologic
Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based
Medicine Conference, Critical Care Grand Rounds, Research Conference,
Fundamental Critical Care Support course.
Content:
Cerebral blood flow/oxygenation/perfusion, encephalopathy and mental
status changes (metabolic/drug-induced/traumatic), cerebral herniation,
seizure activity, intracranial pressure, cerebral blood flow, cerebral metabolic
rate, regional oxygenation, jugular venous bulb oximetry, cerebral cortex
oximetry.
Recommended reading: www.surgicalcriticalcare.net , Irwin and Rippe’s Textbook of
Critical Care, Brain Trauma Foundation Guidelines for Brain Injury
Management
Endocrine
Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based
Medicine Conference, Critical Care Grand Rounds, Research Conference,
Fundamental Critical Care Support course.
Content:
Hypothalamic-pituitary-adrenal axis, cortisol production and deficiency,
ACTH, insulin production and resistance, hypoglycemia, hyperglycemia,
pancreatitis (acute, chronic, alcohol/idiopathic/drug-induced), disorders of
thyroid function (thyroid storm, myxedema coma, sick euthyroid syndrome),
adrenal crisis / insufficiency, diabetes insipidus, diabetes mellitus, disorders
of calcium, magnesium, and phosphate balance.
Recommended reading: www.surgicalcriticalcare.net and Irwin and Rippe’s Textbook of
Critical Care.
Immune Response
Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based
Medicine Conference, Critical Care Grand Rounds, Research Conference.
Content:
Inflammatory cascade, cytokine response (interleukins, leukotrienes,
monocyte response, macrophage response), immunomodulation, physiology
of drotrecogin alfa activated therapy.
Recommended reading: www.surgicalcriticalcare.net and Irwin and Rippe’s Textbook of
Critical Care, www.survivingsepsis.org
Infectious Disease
Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based
Medicine Conference, Critical Care Grand Rounds, Research Conference.
Content:
Antimicrobial
resistance
and
sensitivity,
bacterial
translocation,
pharmacokinetics pharmacologic principles and drug administration,
metabolism of antimicrobial agents, bacterial/fungal/parasitic disease,
systemic inflammatory response syndrome (SIRS),acquired immune
deficiency syndrome (AIDS), complications of antibiotic overuse.
11
Recommended reading: www.surgicalcriticalcare.net and Irwin and Rippe’s Textbook of
Critical Care, www.survivingsepsis.org
Hematologic
Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based
Medicine Conference, Critical Care Grand Rounds, Research Conference.
Content:
Normal and abnormal coagulation, various coagulopathies, blood
components, thrombocytopenia / thrombocytosis, disseminated intravascular
coagulation (DIC), thromboembolic disease, pharmacologic manipulation of
bone marrow response to critical illness, pharmacologic therapies for
coagulopathy.
Recommended reading: www.surgicalcriticalcare.net and Irwin and Rippe’s Textbook of
Critical Care.
Obstetrics / gynecology
Exposure: Daily ICU rounds; Critical Care Teaching Conference; Critical Care Grand
Rounds, Fundamental Critical Care Support course.
Content:
Toxemia of pregnancy; amniotic fluid embolism, HELLP Syndrome,
physiologic changes of pregnancy.
Recommended reading: Irwin and Rippe’s Textbook of Critical Care
Details of Goals and Objectives – Critical Care Skills
Residents on the SCC service have graded levels of increasing responsibility in the performance
of invasive critical care procedures. All of the residents are specifically instructed in the
principles, indications, contraindications, complications, and performance of each of the common
invasive procedures. There is direct faculty supervision of all invasive procedures performed.
The degree of supervision varies with the individual's experience and performance. Residents on
the SCC service also provide assistance and supervision for procedures performed by other
residents in the ICU. Specific procedures performed by the SCC service are described below.
Respiratory airway management including endoscopy and management of respiratory systems
Exposure: Daily ICU rounds; Fundamental Critical Care Support course, Airway
Workshop.
Summary: The SCC service provides all ICU airway management for patients referred to
the service. While many patients are initially intubated in the pre-hospital,
Emergency Department, or operating room setting, any re-intubation or any
elective / urgent airway manipulation is provided by the SCC resident under
faculty supervision. The SCC resident with faculty supervision performs all
bronchoscopies for diagnosis or therapy. The SCC service does all ventilator
management. Specific protocols for airway management are followed and
use of bronchoscopy and endoscopy to assess complex airways are practiced
on a daily basis.
Circulatory: invasive and non-invasive monitoring techniques, including pulmonary artery
catheterization, pulse contour waveform analysis, mixed venous oximetry, application of
transthoracic and transvenous pacemakers, and electrocardiography
Exposure: Daily ICU rounds; Critical Care Teaching Conference, Fundamental Critical
Care Support course.
Summary: The SCC residents, under faculty supervision, perform all hemodynamic
monitoring necessary for patients referred to the SCC service. Modalities
used during the average year include arterial lines, central venous
catheterization, volumetric continuous cardiac output pulmonary artery
catheterization, arterial pulse contour waveform analysis, measurement of
12
mixed venous blood gases, calculation and interpretation of ECGs, treatment
of acute arrhythmias, the use of transvenous pacemakers, the use of external
pacemakers, and intracranial and intra-abdominal pressure monitoring.
Maintenance of these devices and calculation of all hemodynamic variables
are performed by the SCC service. Residents are instructed in the indications
for echocardiography and the application of the information obtained, but
technicians or consulting cardiologists perform the actual procedures. Cardiac
assist devices are not used in the Surgical ICU's. Patients requiring such
devices are transferred to the Cardiovascular Recovery Room (CVRR) as per
ICU policy.
Neurological: the performance of complete neurological examinations; use of intracranial
pressure monitoring techniques; application of hypothermia in the management of cerebral
trauma; performance of apnea testing for brain death determination
Exposure: Daily ICU rounds; Critical Care Teaching Conference, Evidence-based
Medicine Guidelines, Fundamental Critical Care Support course.
Summary: The residents are directly involved in the care of head trauma and postoperative neurosurgical patients. All care of neurosurgical patients is shared
with the neurosurgery service and neurosurgical attendings. Treatment
modalities include maintenance and calibration of intracranial pressure (ICP)
monitors, interpretation and treatment of ICP problems, and the management
of cerebral perfusion pressure, barbiturate coma, vasospasm, and
optimization of cerebral perfusion pressure. ICP monitors are placed by
consulting neurosurgeons or by SCC residents under their direct supervision.
Maintenance of the devices, indications, contraindications, complications, and
application of information obtained from the devices is a part of daily teaching
rounds and regular didactic conferences. Computer assisted continuous EEG
monitoring is used in the Neurosciences ICU and the data are reviewed and
discussed on a daily basis on ICU teaching rounds.
Renal: the evaluation of renal function, peritoneal dialysis and hemofiltration, knowledge of the
indications of complications of hemodialysis.
Exposure: Daily ICU rounds; Critical Care Teaching Conference.
Summary: Avoidance of acute renal failure and application of renal protection protocols is
a part of daily ICU teaching rounds. This highly successful program has
almost completely eliminated oliguric renal failure and the need for
hemodialysis.
The various renal replacement techniques including
hemodialysis are discussed in didactic conferences and used on occasion in
daily patient care. Management of acute renal failure and indications,
contraindications, and complications of renal replacement therapies are
discussed in regular didactic conferences. The SCC residents work closely
with the nephrology consultants to plan the method, timing, and objective of
each renal replacement intervention. Goals of each treatment are jointly
reviewed to include electrolyte imbalances, acid-base disturbances, and
volume status.
Gastrointestinal: utilization of gastrointestinal intubation and endoscopic techniques in the
management of the critically ill patient; application of enteral feeds, management of stomas,
fistulas, and percutaneous catheter devices.
Exposure: Daily ICU rounds; Critical Care Teaching Conference.
Summary: Gastrointestinal tubes, stomas, and fistulae are a common part of general
surgery and are managed jointly by the primary surgical services and the SCC
residents.
The SCC residents routinely perform intubation of the
gastrointestinal tract for feeding, diagnosis, or therapy. The SCC residents,
under the direct supervision of the SCC attending surgeon, perform upper
gastrointestinal endoscopy for diagnosis and for placement of percutaneous
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endoscopic gastrostomy (PEG). Indications, contraindications, complications
and management are discussed in daily SCC teaching rounds and routinely in
didactic conferences.
Hematologic: application of autotransfusion, assessment of coagulation status, appropriate use of
component therapy.
Exposure: Daily ICU rounds; Critical Care Teaching Conference.
Summary: Autotransfusion, assessment and treatment of coagulation abnormalities and
transfusion of homologous blood components is a part of daily SCC patient
care.
Indications, contraindications, complications, and management
strategies are discussed on daily teaching rounds and routinely in didactic
conferences. The assessment of coagulation and use of component therapy
is part of the care of virtually every patient in the ICU.
Infectious Disease: classification of infections and application of isolation techniques,
pharmacokinetics, drug interactions, and management of antibiotic therapy during organ failure,
nosocomial infections
Exposure: Daily ICU rounds; Critical Care Teaching Conference, Fundamental Critical
Care Support course.
Summary: Diagnosis, treatment, use of antimicrobials, and adjuvant therapies are
discussed in daily teaching rounds and routinely in didactic conferences. A
doctor of pharmacy level pharmacist with special interest in antimicrobials and
infectious disease is a member of the SCC teaching service and contributes to
daily teaching rounds and conferences. When consultation from the Infectious
Disease department is requested, the SCC resident interacts directly with the
consultant as part of their educational experience. Evaluation of unit microbial
flora and antibiotic sensitivity and guidelines using this information for use of
antibiotics are developed and used for the care of all patients. The SCC
service follows standard protocols for the prevention and management of
nosocomial infection. In addition, we have specific procedures and policies for
containment and body substance isolation practice to which the residents are
exposed.
Nutritional: application of parenteral and enteral nutrition; monitoring and assessing metabolism
and nutrition.
Exposure: Daily ICU rounds; Critical Care Teaching Conference.
Summary: Virtually all patients referred to the SCC service receive specialized nutritional
support while in the ICUs. Enteral nutrition is utilized preferentially with total
parenteral nutrition limited to specific indications. The SCC resident, under
supervision of the faculty, directs the selection and administration of the
support. Protocols are in place for routine nutritional assessment including
nitrogen balance and metabolic expenditure studies. Residents on the SCC
service use this information to formulate a comprehensive nutritional support
plan.
Representatives from the institutional Nutritional Support Team
contribute to teaching rounds on a daily basis. Indications, contraindications,
complications, and management details are discussed on daily teaching
rounds and routinely in didactic conferences. The residents have hands on
experience with direct and indirect calorimetry measurements.
Monitoring/bioengineering: use and calibration of transducers, amplifiers, and recorders.
Exposure: Daily ICU rounds; Critical Care Teaching Conference.
Summary: Basic and specialized monitoring devices are used in all patients admitted to
the ICU. The SCC residents interpret and apply the information obtained from
the devices on a minute-to-minute basis. The principles of the devices,
indications, contraindications, complications, and applications are discussed
on daily teaching rounds and routinely in didactic conferences.
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Miscellaneous: use of special beds for specific injuries, traction, and fixation devices.
Exposure: Daily ICU rounds; Critical Care Teaching Conference.
Summary: Specialized beds, immobilization and mobilization devices, mechanical and
chemical techniques for prevention of venous thrombosis and embolization
are discussed on daily teaching rounds and routinely in didactic teaching
conferences. The use of special beds for pulmonary problems including
rotational beds and prone ventilation devices is part of daily experience. The
physiology and application intra-abdominal pressure monitoring is
emphasized.
V. RESIDENT RESPONSIBILITIES
SCC residents will take in-hospital call approximately every third to fourth night depending upon
the number of general surgery and emergency medicine residents on service. During their times
on-call and during their normal daily activities, the SCC residents have the responsibility of
carrying out the patient care plan that is mutually agreed upon by the primary surgical team and
the SCC service. In general, the primary surgical team retains complete responsibility for
development of the patient care plan. While administering the patient care plan, the SCC
resident has an appropriate amount of latitude regarding clinical decision making and modification
and execution of the care plan. However, should unforeseen circumstances occur, it is the
responsibility of the resident to immediately notify the patient care team in order to establish a
new patient care plan. Delivery of the patient care plan is under the direct supervision of the ICU
attending surgeon. An attending surgeon supervises all technical procedures.
General surgical residents and other residents assigned to the ICU make daily morning work
rounds with the primary surgical teams in order to exchange information and develop a patient
care plan for the current day. Following these early morning rounds, the SCC residents
participate in detailed patient care / teaching rounds with the ICU attending, general surgery and
emergency medicine residents, and medical students. During these detailed rounds, all aspects
of patient management are reviewed with the ICU attending. The patient care plan, as jointly
discussed with the primary surgical team and the SCC service, is also reviewed during these
rounds. If modifications to the daily care plan are recommended, they are discussed between the
two services.
FIRST AND FOREMOST, remember that the patient belongs to the attending physician and that
the final decision and ultimate responsibility for the patient’s outcome always lies with this
surgeon or his/her designee. In the ORMC ICUs, a distinction is made between the patient’s
“attending” physician and the patient’s “managing” physician. For some patients, the attending
and managing physician will be the same. For others, in which the attending physician may not
feel comfortable directing the critical care management of the patient, the designated “managing”
physician (usually an intensivist) will direct the patient’s day-to-day ICU care. Both the attending
and managing physician may also delegate another physician, the senior resident on the primary
service, or a consulting physician to make specific patient care decisions.
For every patient on the “teaching” services (“Blue” or “Red”) of the Department of Surgical
Education, the SCC Service will be designated as the patient’s managing physician. The SCC
Service will make all patient care decisions in conjunction with the patient’s chief surgical
resident. The SCC Service will also frequently be designated as the managing physician for
“private” general surgical and vascular service patients. In these cases, the SCC Service will
manage the day-to-day ICU care, but ultimate decision making responsibility remains with the
patient’s private surgical attending. The degree of patient care involvement assigned to the SCC
Service on these private patients varies from surgical attending to attending. You will come to
know each surgeon’s preferences during your first month or two in the ICU.
15
All plans, procedures, non-routine physician’s orders and diagnostic tests, consultation requests,
and therapeutic or management changes will be discussed with the primary surgical team. All
adverse occurrences, complications, condition changes, and unexpected test results must be
immediately communicated to the primary surgical team as well. Documentation of the
discussion and rationale for the actions and therapy instituted should be documented in the
Progress Notes section of the patient’s medical record.
Communication between the SCC Service and the primary surgical services should be at the
senior resident, chief resident, or attending level. Unlike on the regular patient care floors,
communication up and down the traditional chain of command with junior level residents can
cause confusion and delay therapy. Communicate with the SENIOR resident as much as
possible.
Both the residents on the primary surgical services and the SCC residents make rounds and
document their patient care activities, assessment, and plans in the patient's medical record as
frequently as is indicated. Thus, two sets of daily patient care notes are generated each day.
The residents rotating on the SCC service for one to two months are members of the general
surgery or emergency medicine residency programs. During their rotation, they receive an
intense experience in critical care closely supervised by the SCC attendings and SCC residents.
The SCC residents enhance the educational experiences of the general surgery and emergency
medicine residents by providing close supervision of junior residents and contributing to the
teaching conferences attended by these residents. They work as peers to the senior and chief
residents in the general surgical program and share in the management of the complex patients
admitted to the critical care units.
This parallel approach to patient management is intended to improve patient care by making
resident and attending physicians available immediately at all times in the critical care units. The
program is intended to improve educational efforts in critical care by providing an intense
experience for the sponsoring program junior and senior level residents during their rotations on
the SCC service. It also provides continuing experience in critical care for senior level and chief
residents as they round throughout their entire training program with the ICU attendings and
residents.
Administrative Resident
The Administrative Resident is responsible for the organization of the Surgical Critical Care
service and the direction of the residents and medical students rotating upon it. These
responsibilities are equally divided, by month, between the SCC residents. This is an opportunity
to begin to hone your skills in ICU administration and direction. The duties of the Administrative
Resident include:




Orientation of new residents (General Surgery, Emergency Medicine) and visiting
medical students to the SCC Service including expectations and responsibilities
Didactic teaching with residents and medical students
Preparation of ICU call schedule (submit to Cynthia 2 weeks before the start of the
next month)
Monthly resident and medical student evaluations
16
2007 - 2008 ACADEMIC YEAR
Month
Administrative Fellow
July
Straus
August
Straus
September
Straus
October
Withers
November
Withers
December
Withers
January
Straus
February
Straus
March
Straus
April
Withers
May
Withers
June
Withers
VI. JOINING THE SURGICAL CRITICAL CARE TEAM: A DAY IN THE LIFE.
THE DAY-TO-DAY WORKINGS OF THE SURGICAL CRITICAL CARE SERVICE
The first few months of the residency involve a difficult period of adaptation not only to the
microenvironment of the ICU but also to the macro-environment of Orlando Regional Medical
Center (ORMC). The new SCC resident will need some time learning to get around a new
institution and interact with personnel at different professional levels.
The ICUs at ORMC
SCC residents rotate on the “Surgical Critical Care Service” for ten months of their 12-month
residency. During this time, they care for patients in all of the ICU’s at ORMC. The typical
census for the SCC Service is 15-25 patients divided among the various ICUs with the majority of
the patients residing in the Trauma ICU. While the ICUs at ORMC are typically considered to be
one unit for the purpose of training, the individual units and their specialty include the following:
 Trauma ICU (14 beds)
 Surgical ICU (8 beds)
 Neurosurgical ICU (10 beds)
 Medical ICU (8 beds)
 Coronary Care Unit (12 beds)
 Cardiovascular Recovery Room (8 beds)
The Winnie Palmer Women’s and Babies’ Hospital (WPH), which is on the same campus as
ORMC, serves the obstetric and gynecologic patient population of Central Florida. They are
currently developing a five-bed ICU for the care of women who develop critical care issues during
their obstetric / gynecologic care. Historically, these women have been transferred to the ICUs at
ORMC for critical care management. Within the next year, it is anticipated that some of the less
critically ill women will be kept at WPH and that the SCC service will direct their ICU management
in the WPH ICU. This is considered by ORH to be the same site as WPH and ORMC reside on
the same campus.
The Nursing Staff
On an hourly basis, the people that you, as the SCC resident, will spend the most time with will
not be the faculty or housestaff, but rather the nursing staff. It cannot be stressed strongly
enough that it is vital to be able to work constructively and amicably with the nurses.
Good rapport with the staff will lead to better patient care. Most of the nursing staff are highly
trained and experienced, and possess sound clinical judgment. You will depend on them for
accurate information, early warning of potential problems, execution of the complex orders, and
set up and use of the multiple, complex monitoring devices commonly used in the unit today.
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There is a period of mutual readjustment at the beginning of each academic year for both the new
fellows and the nurses. Try to make this a smooth transition for all involved, as a little extra time
up front will both save later headaches and provide a good working relationship down the line.
Remember that the ICU cannot run smoothly (or at all) without experienced, dedicated nurses,
which means that you cannot do your job effectively without the nurses. Also remember that
many of the nurses you encounter in the ICU were practicing critical care before you even
considered medical school and will continue to be at ORMC long after you leave! Approaching
your fellowship with a mind open to learning from the ICU nursing staff will provide you with
immeasurable and long lasting benefits.
ICU Morning Rounds
The main event of a day in the ICU is morning rounds. Rounds starts at 0800 in the TICU and
last for 2 - 4 hours. The resident on-call must be physically present at all times during rounds in
order for this session to achieve its objectives. All residents and students rotating on the SCC
Service should participate actively during rounds. The fellow should be prepared to supplement
the general surgery or emergency medicine resident and the medical student presentations with
additional relevant information as necessary. Special emphasis is placed on the events of the
previous 24 hours. The fellow's contribution is especially important when attendings switch each
Monday, especially if the new ICU attending has not been on-call for some time. Since the
presentations stress the most recent events, the fellow must be sure to mention all significant
events that have occurred since the attending last saw the patient. Representatives from nursing,
pharmacy, respiratory care, nutritional support, and the primary service should each add their
pertinent comments. Each patient presentation is followed by a discussion of the case by the ICU
attending including the pertinent teaching points. After discussion of alternatives and questions,
the plan for the next 24 hours is laid out. It is extremely important that communication is clear at
this point and that the on-call resident or fellow has a complete understanding of the interventions
to be made. The resident/fellow should not try to keep this in his/her memory, but notes should
be taken so that specific plans are not forgotten, resulting in significant omissions coming to light
during evening rounds.
The off-duty resident/fellow may need to handle acute problems during the course of rounds;
he/she is encouraged to do so since he/she is abreast of the most recent events. If the continued
presence of a physician is required at the bedside, one of the residents/fellows not assigned to
patient care that day (i.e., the "in-between team") should leave rounds and manage the problem.
Nothing disturbs morning rounds more than waiting for the post-call fellow to return from a
bedside with vital information.
The last subject of morning rounds is discharges, admissions, elective and emergency consults.
The fellow should scrutinize the daily OR schedule prior to rounds and discuss planned or
potential admissions with the ICU Charge Nurse. A plan is delineated at this time concerning
admissions for the next 12 hours. The charge nurse is a pivotal participant of this discussion
since he/she is aware of any staffing problems that might affect bed allocation or the potential
acuity of the possible admissions, as well as about the availability of step down beds for
transferring patients ready for discharge. It also pays to get to know the nursing coordinators
(known as the "PCC") who will know the hospital's bed situation.
The ICU nurses and therapists are a vital source of information about the patient. They are
in close contact with the patient for 12 hours a day while you, as the fellow, must divide your time
between 15-25 patients. The nurse can frequently tell you about the primary team's last visit, the
opinions and recommendations of consulting services, and the family's understanding of and
questions about the patient's condition.
Patients should be assigned to junior residents and students before morning rounds. Otherwise,
3 hours of rounds could go by and, at the end when patients are assigned, residents may only
vaguely remember the specific plans laid out. At no time should more than 3 patients be
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assigned to medical students. This enables each member of the junior staff to concentrate on the
remaining patients.
Although the junior residents and medical students will generally follow those patients admitted
on their nights on call, it may be better (at times) to rotate patients among residents to increase
their exposure and, thus, their learning experience. In generally, students should not be assigned
chronic, long-term patients. Continuity of care, however, is necessary at the fellow level.
Work rounds include a methodical review of the flow sheet including close scrutiny of each
system, emphasizing the patient's main problems:
Cardiovascular
Check vital signs
Check hemodynamic parameters and monitoring devices (obtain new values if indicated)
Review cardiovascular drips and adjust as necessary
Respiratory
 Check ventilator settings and blood gas results
 Check pulse oximeters and mixed venous oximeters
 Calculate Qsp/Qt and Vd/Vt (when necessary)
 Check adequacy and frequency of respiratory orders (chest physical therapy, aerosol
treatments and oxygen therapy); evaluate the need for new orders or need to
continue the current ones
 Only fellows or experienced senior residents should make non-emergent
ventilator changes. Students are NOT allowed to make ventilator changes
without the fellow or respiratory therapist in attendance.
 All ventilator changes must be IMMEDIATELY documented on the patient’s
flowsheet and in the Physician Orders. Both the nurse and the respiratory
therapist should be notified of any ventilator changes.
Renal
Check urine output and renal function parameters with special attention to trends.
Check volume status and the continued need for potentially nephrotoxic medications.
Metabolic
 Evaluate fluid balance and adequacy of fluid orders in volume and composition.
 Check results of follow up serum and urinary chemistries, arterial blood gases, blood
glucose levels and insulin drips.
 Lactic acid levels should be measured in patients with unexplained metabolic
acidosis or until lactate levels return to normal (less than 2.0 mmol/L).
Nutrition
 Assess nutritional status and need for supplementary nutritional support
 Check recent metabolic cart and UUN studies
 Check the most recent recommendations by the nutritional support team
 Reconsider route of current nutritional support and possibility of new routes
 Check TPN solution type and additives.
Hematologic
 Check hemoglobin and WBC; trend values and evaluate for changes
 Assess clotting variables, platelets,
 Evaluate for potential sources of bleeding
 Check for medications that could be suspected of causing hematologic abnormalities.
19
Gastrointestinal
 Examine every abdomen and evaluate status of wounds
 Consider need for continuation of drains and tubes
 Communicate important findings which seem to have been missed by surgical team
(not mentioned in notes or discussions).
Infectious Disease
 Investigate fever spikes, WBC elevations
 Consider need for new or repeat cultures, need for line changes, need for special
cultures
 Consider continued need for antibiotics, status of antibiotic regimen and need for
changes
 Culture results and antibiotic changes should be recorded
 Discuss antibiotic levels with the clinical pharmacist.
 New antibiotic orders and antibiotic level orders should be written.
Neurological
 Recheck the Glasgow Coma Scale reported in morning rounds, address any acute
changes
 Adjust narcotics, sedatives and psychoactive drug
 Evaluate the need for delirium tremens prophylaxis
 Check serum sodium (goal = 150-155 mEq/L) and osmolarity (goal = 305-320
mOsm/L) on patients receiving mannitol or hypertonic fluids; adjust as necessary
 Adjust anticonvulsants according to serum levels
 Adjust ventilation (if indicated) to maintain a PaCO2 of 30-35 torr
 Check pupils for reactivity.
The nursing medicine administration record (MAR) should also be reviewed online paying special
attention to all the medications the patient is receiving. A close watch should be maintained for
adverse reactions and dosages should be adjusted according to changes in renal or hepatic
function. Reordering medications should be part of morning rounds. IV fluids and rate of
administration should be checked. The microbiology data must be checked once it is updated
after 9:30 AM each morning.
The junior residents should be encouraged to do the order writing during this part of rounds so
that they become familiar with the doses and with order writing in general. All medical student
orders must be co-signed by a physician. It is important that the reasoning for all the
decisions be explained to all involved parties: junior staff, students, nursing staff,
respiratory therapists, surgical teams. This constitutes the most important teaching goal
of bedside rounds.
After the flowsheet and medications have been reviewed and appropriate interventions have
been made, specific activities are delegated by the fellow to the junior staff and students. The
connotation of the term delegation is very important: ultimately the ICU attending considers
the fellow the responsible party; therefore, he/she should assess the capabilities of the junior
staff and constantly follow the progression of the task that has been delegated.
As previously stated, contacting consultants, scheduling special tests, and obtaining official
results of radiological or other clinical tests is an important early priority. Only after those things
have been done should the fellow concentrate on other time consuming activities.
The next priority is invasive procedures. Elective line placement and changes should be
completed before the change of the nursing shift, preferably before 1800 so the ICU attending
can be present and before the nurses are busy completing the flowsheets for their evening report.
20
Family Rounds
Speaking with families is part of the 4 PM afternoon rounds agenda and usually is a very
rewarding activity. The importance of good communication between the physicians and patient
families cannot be stressed strongly enough. This cannot be delegated to junior staff. It is best
to maintain communication with the family at the attending and fellow level in order to provide
consistent information from the coordinator of patient care to the concerned family member.
Students and junior residents should direct family's questions to the fellow. Ideally, two people
are present when talking to the family including a fellow, attending (especially if there is a
problem), nurse, and/or surgical team member. The second person can act to verify information
and to assess the family's reaction.
Being in the operating room most of the day, the primary services are frequently not available to
talk with families. It is not unusual to hear family members say they have not talked with a doctor
"in several days". The fellow becomes an important source of information and assurance to
many families. Try to be present during visiting hours and accessible to family members. The
nurses will frequently ask you to update the family if they have not seen the primary service
recently. It takes but a few minutes, fulfills the family's need to talk with a physician, allows you to
get to know the family, and can be very rewarding. Obviously any sensitive issues should be
discussed between the family and attending surgeon. If you sense any discomfort with the
family's relationship with the primary service or any perceived problems in patient care, these
items should be immediately brought to the attention of the patient’s primary surgeon.
Early Evening
Ask the ICU Charge Nurse to inform you of all potential admissions and of all admissions as they
actually arrive in the ICU. Make a point of "checking in" with the charge nurse every few hours to
find out the latest information on admissions, patients in the Emergency Department (who may
become admissions), transfers, and the hospital bed status. More often than not, the ICU is
nearly full with only 1 or 2 potential beds or "admissions slots". Triage of stable patients out of
the ICU to accommodate critically ill patients should always be in the back of your mind. The
hospital in general also stays at a high occupancy rate and floor beds may not always be readily
available. Always keep in mind which bed will be used as the admission slot for a cardiac arrest
from the floor, an unexpected OR patient, or the trauma patient that needs emergent
resuscitation. Close communication with the ICU Charge Nurse is essential and will prevent
surprise admissions as well as allow you to budget your time and plan procedures. Reviewing
the operating room schedule first thing in the morning and discussing these potential admissions
with the charge nurse will allow you to anticipate and plan their care in advance.
New admissions introduce variety to the afternoon. Usually, elective admissions of the day arrive
from the operating room and require the devoted attention of the fellow and junior resident in
charge of the patient at least for the first 30 minutes. Obtain a direct report from the
anesthesiologist, CRNA, or surgeon to assess the condition of the patient and to evaluate for
potential instability. Remember to inform the ICU attending about the new admissions and to
have a plan of action for discussion.
The student/resident should write an admission note with details of the history, reason for
admission to the ICU, intraoperative course, intraoperative complications, admission physical
examination and results of admission blood work and CXR, assessment and plan. Such a note is
of use not only for presentation of the patient to the attending, but as a summary for the incoming
team. The note should be concise and limited to no more than one page.
As long as the plans made during morning rounds and adjusted in afternoon rounds are being
followed and no new or significant developments have occurred, there is no need to call the
attending. If things are not "going well", problems have developed, or you are not sure how to
handle a particular problem, it is best to call the ICU attending and talk it over. It cannot be
21
stressed enough that the ONLY ERROR IS NOT CALLING. As time goes on and you learn and
develop competence and confidence, trust between attending and fellow also grows and you will
have plenty of time for independent action. This is not true in July! Before calling the attending,
all the information pertinent to the problem should be collected and tentative and alternative
strategies thought out.
Evening Pre-Rounds
The on-call resident will update the status of the patients, occurrences of the day and changes
made to the plans discussed during morning rounds. New consults will be examined and worked
up. Be sure to discuss the bed situation with the ICU Charge Nurse before the evening checkout
phone call to the ICU attending. A plan for triage and acceptance of patients must be formulated
to optimize bed utilization and expedite admissions. The flowsheets of particularly complex
patients should be collected in preparation for the attending phone call and the quietest area of
the unit selected to sit down and call the attending.
Evening “Checkout” Rounds
Evening checkout rounds are at either 9 or 10 PM each evening (check with the ICU attending to
determine their preference). This session is a phone conversation between the ICU attending
and on-call fellow/resident. This is an opportunity for the fellow/resident to have a one-on-one
discussion with the attending. Using the flowsheet as a source of information, the fellow
describes the events of the day, the results of the interventions, and conveys the useful
information that he/she has collected. He/she is expected to summarize and abstract the crucial
facts, avoiding irrelevant trivia. The news story approach is strongly suggested: who, what,
where, when, and how in the first paragraph. The events of the evening are discussed including
intervention and patient care plans. Clarification of plans, potential triage patients, new
admissions, and preoperative evaluations are all discussed. Again, no question should remain at
the end of the conversation as to the plan of action for the night. The fellow/resident should ask
for any necessary clarification and write down the plans laid out in order to avoid errors and
omissions. Rounds are finished with the presentation of new consults as well as any outstanding
emergency consults. Advance plans should be made for potential discharges the next morning
as well as discussing bed availability for the next day's elective cases.
Night Work Rounds
Appropriate laboratory studies for the next day should be ordered: there are no "routine" morning
labs. Every test should be ordered for a specific reason. Considering the acuity typical to most
patients, it is not unusual to have at least a CBC (hemoglobin and white blood cell count) and
electrolytes. As a guideline, one CXR should be obtained every 24 hours for intubated patients,
but only for specific indications on non-intubated patients. Routine chest X-rays are not needed
after guidewire line changes. The overall plan of care should be discussed with the night nursing
and respiratory staff and all questions answered so that the teaching objectives of rounds are
accomplished for the night crew. All orders should be entered into Sunrise XA; verbal orders are
for true emergencies. A physician must co-sign the student's orders at the time the order is
written.
Many emergency admissions arrive in the ICU after midnight. They also usually constitute the
more complex cases (either trauma cases with multiple injuries, cardiovascular and respiratory
instability or elective surgical patients with acute cardiorespiratory decompensation and/or
sepsis). These cases require immediate attention by on-call resident since the entire database
must be created from scratch. Information should be collected rapidly from all sources while, at
the same time, therapeutic measures are instituted and monitoring devices are inserted. When
the "busy work" is completed, an admission note must be written, containing the list of problems,
diagnosis or injuries, work up, an admission physical examination, the results of admission lab
results and CXR, and finally, an overall assessment and therapeutic plan. Be sure to check to
see that the patient and any procedures are entered into the Surgical Education database.
22
One of the busiest periods in the ICU occurs from 0600 until 0800. During this time, the fellow is
expected to review daily progress notes, exchange information with the residents of all the
various surgical teams, review all the morning X-rays, review all the new lab data (and institute
corrective measures for any abnormal values), find results of important gram stains sent over the
previous 24 hours, obtain preliminary readings on radiological studies done overnight, discuss the
projected discharges and admissions with the incoming charge nurse, answer questions from the
operating room staff, recovery room staff and surgical teams regarding bed availability for elective
cases and receive new emergency consults from the trauma and other surgical teams. All these
activities are spiced by a multitude of patients' developments brought to the fellow's attention by
the incoming nursing shift. It is at this time when the fellow's ability to handle multiple problems at
the same time is taxed the most!
Daily progress notes should consist of a brief summary of the events of the previous 24 hours.
These serve as the most knowledgeable and concise listing of events and decisions. Since the
attending dictates a comprehensive note during morning rounds, the fellow/resident/student note
should covers the highlights and focus on the plan rather that rewriting of data already written on
the flowsheet
Close communication should be maintained with the ICU attending throughout the night: when a
patient is not responding in the expected fashion, when the fellow has any doubts or even when
the attending might want to know about a successful outcome of a therapeutic intervention in a
complex case.
Admissions
There is a general order for prioritizing admissions when a bed becomes available. This is
detailed in the ICU Bed Allocation Protocols. In brief, unstable patients in the Emergency Room
who will require invasive critical care monitoring or pulmonary support always have first priority for
admission. Unstable patients from the floor or step-down units are the second priority. Unstable
patients from the operating room are considered next. Pre-operative cardiopulmonary evaluation
patients represent a special group of patients who are given a high priority for admission by virtue
of their potential for becoming critically ill postoperatively. Only after the above patients are
admitted are the more routine admissions assigned beds. It is often useful to make a trip to the
recovery room, emergency department, operating room, or floor to evaluate patients before
assigning them an ICU bed. Frequently, what constitutes an “ICU admission” in someone else’s
mind will just as appropriately be cared for in a step-down unit bed.
Standardized, pre-printed orders for admission to the ICU are available on Sunrise XA. Patients
admitted to the ICU are strongly encouraged to have these orders filled out. All admission orders
should be written or co-signed by a senior resident of the surgical team. The on-call resident
must review the orders written by the team to make any necessary changes and additions.
Discharges and Transfers
A patient is ready to be discharged from the ICU when critical care management is no longer
needed or the reason for intensive monitoring either by medical or nursing staff is over. Both the
SCC service and the surgical team must agree on this before the actual discharge occurs.
Specific transfer criteria and step-down unit admission criteria are available in the ORMC policy
and procedure manual. Sometimes disagreements may arise regarding the fitness of the patient
for discharge, or the need for a step-down or intermediate care unit. These disagreements are
usually ironed out when the teams have an open discussion of the case either at the
fellow/resident level or, if necessary, at the attending level.
Patients and families should be prepared for the transfer to the floor or step down unit ("cutting
the umbilical cord") particularly after prolonged ICU stays. If the patient is transferred in the
middle of the night, the family should be prepared and notified in advance. Usually the ICU team
23
is more conservative with respect to placing the patient in an intermediate care unit but,
ultimately, the surgical team is responsible for the disposition of the patient after discharge from
the unit. All discharges and transfers should be reviewed by the ICU attending (NO
EXCEPTIONS).
Transfer orders must be in the chart or entered into Sunrise XA before the patient leaves the ICU.
It is important to have the senior resident of the surgical team write orders as soon as discharge
is agreed upon so there are no delays when the step-down unit or regular ward bed becomes
available. Patients with continued critical care problems may be followed by the ICU team until
they are transferred from the step down unit (PCU).
VII. RESIDENT EVALUATION AND THE CORE COMPETENCIES
SCC residents are expected to demonstrate the skills, knowledge, and attitudes necessary to
meet the requirements of the core competencies listed below. Residents receive education on
the core competencies through exposure during daily ICU rounds and the scheduled department
teaching conferences. Fellows are evaluated using a number of methods as outlined below.
Evaluations are performed on a quarterly basis and reviewed with the program director in a oneon-one meeting. Copies of the evaluation forms used to evaluate the fellows are included.
A. Evaluation of the Resident by Faculty
Evaluation of each SCC resident occurs on a contemporaneous ongoing basis through
daily feedback and personal interaction between the residents and the faculty. In
addition, a formal performance evaluation of the resident by each faculty member is
completed every three months using the Core Competencies. The development of
appropriate technical skills by each resident is evaluated by the faculty every six months.
These evaluations are discussed with each individual resident during quarterly evaluation
sessions with the program director.
Each resident will be required to maintain a case log of all bedside and operative
procedures performed during the residency. This will allow the resident to review and
maintain an active understanding of their experience and adjust during the year for any
inadequacies. Such a log is also necessary to apply for the American College of
Surgeons Added Certificate of Qualification in Critical Care upon completion of the
residency.
B. Evaluation of the Resident by Peers and Students
The resident will be formally evaluated by the general surgery and emergency medicine
residents as well as by medical and physician’s assistant students rotating upon the
service. These evaluations will be discussed with the SCC resident during the quarterly
evaluation sessions.
C. Evaluation of the Resident by the Nursing and Respiratory Therapy Staff
The resident will be formally evaluated by the ICU nursing and respiratory therapy staff
on a quarterly basis using an anonymous online “360 degree” evaluation. The results of
these surveys will be discussed with the SCC resident during the quarterly evaluation
sessions.
D. Evaluation of the Faculty and Program by Resident
The residents will be expected to evaluate the faculty using standardized forms on a
quarterly basis. Each resident will also participate in an annual program review session
in which the core objectives and goals will be re-evaluated and recommendations made
as to how to modify and improve the program. Residents are encouraged to discuss any
issues or concerns regarding the residency program, their progress in the residency, and
the correction of any identified problems with the program director at any time.
24
The Core Competencies
1. Patient Care:
a) Effectively lead patient care with clear communication to team, patients, family, and
attendings
b) Accurately synthesize complex clinical data and propose clear treatment plans
c) Actively lead team decision making
d) Capably perform procedures suitable to surgical critical care patients with attending
supervision
2. Medical Knowledge:
a) Demonstrate effective decision making based on adequate knowledge
b) Effectively correlate basic science knowledge with clinical scenarios
c) Exhibit a desire for additional knowledge
d) Appropriately use learning resources
e) Be fluent with pharmacology and physiology as it pertains to surgical critical care
i) Be familiar with the current literature
ii) Demonstrate an investigatory and analytical thinking approach to clinical
situations
3. Practice-Based Learning and Improvement:
a) Participate in scheduled conferences
b) Knowledgeable of evidence-based medicine as applied to critical care
c) Adequately use scientific data to help solve clinical problems
d) Actively contribute to the team’s education by providing recent and current data as a
result of literature searches
4. Interpersonal and Communication Skills:
a) Maintain professional, cordial, and compassionate relationships with patients, staff,
co-workers and faculty
b) Demonstrate the ability to listen and to accept constructive criticism
c) Demonstrate the ability to communicate efficiently with team members, attendings,
referring and consulting physicians
5. Professionalism:
a) Demonstrate compassion, respect and integrity in the work environment
b) Flawlessly uphold the professional standards of the surgical critical care / trauma
services
c) Respect differences in gender, age, culture, disability or educational levels
d) Contribute to all educational activities of the surgical critical care / trauma services
e) Committed to ethics of confidentiality and informed consent
6. Systems-Based Practice
a) Understand one’s position within the team, specialty, profession and society
b) Demonstrate sensitivity and awareness at the cost of health care delivery
c) Advocate for cost-conscious and effective patient care
d) Develop skills as a “team leader”
e) Develop administrative skills to organize and lead a busy clinical service
25
ORLANDO REGIONAL MEDICAL CENTER
DEPARTMENT OF SURGICAL EDUCATION
FACULTY EVALUATION OF SURGICAL CRITICAL CARE RESIDENT 2007 - 2008
Resident Name:
Quarter:
Instructions: Please evaluate the above SCC resident based upon your recent
experiences:
SCALE: 5=Outstanding, 4=Very Good, 3=Good, 2=Fair, 1=Poor
Please rate the resident on the following core competencies:
PATIENT CARE
 Communicates well with patients, family and colleagues
 Attentive to detail
 Participates in team decision making
 Leads/mentors residents regarding patient care issues
MEDICAL KNOWLEDGE
Able to integrate basic science concepts into clinical practice
Up-to-date with recent scientific discoveries/developments
Demonstrates organized thinking
Able to effectively teach
Provides high quality patient presentations
CLINICAL PERFORMANCE
Effectively manages critical issues in the ICU
Effectively leads a multidisciplinary patient care team
Technically proficient in ICU procedures
Able to multitask
PROFESSIONALISM / INTERPERSONAL SKILLS
Demonstrates respect and integrity in work environment
Demonstrates compassion to patients and families
Able to listen to others and respect people with different opinions
and/or backgrounds
Relates to others in a cordial, respectful manner
Works effectively with others
Committed to the ethical principles of the profession
Is eminently educable
Able to accept criticism
SYSTEM-BASED PRACTICE
Understands the role of the Surgical Critical Care Service in relation
to the patient’s overall care
Sensitive to issues related to cost of health care delivery
Able to understand one's position in the team
Assures safe patient disposition and continuity of care
PRACTICE-BASED LEARNING
Analyses own clinical practice and improves it
Locates and applies scientific evidence to patient care
Understands formulation of hypothesis, study design and statistical
methods
Facile with scientific and medical tools available on the Internet
Effectively teaches residents, students, and others
5
4
3
2
1
NA
26
ORLANDO REGIONAL MEDICAL CENTER
DEPARTMENT OF SURGICAL EDUCATION
COGNITIVE AND CRITICAL CARE SKILLS EVALUATION 2007 - 2008
Fellow Name:
First 6 months
Second 6 months
COGNITIVE KNOWLEDGE
(Please check the appropriate box)
Knowledge
Learning,
Absent or
Not
able & able Knowledge
but
inadequate Observed
to teach
able
incomplete
CARDIOVASCULAR PHYSIOLOGY / PATHOLOGY
Principles of electrocardiographic monitoring
Cardiac rhythm and conduction disturbances
Hemodynamic monitoring:
Principles of strain gauge transducers
Principles of arterial, central venous and pulmonary artery
pressure catheterization and monitoring
Assessment of cardiac function and derived hemodynamic
parameters
Principles of oxygen transport and utilization
Shock states (hypovolemic, cardiogenic, distributive, neurogenic,
endocrine)
Vasoactive and inotropic therapy
Myocardial infarction
Pulmonary embolism - thrombus, air, fat, amniotic
Pulmonary edema - cardiogenic, noncardiogenic
Cardiac tamponade & acute pericardial diseases
Management of hypertensive emergencies & urgencies
RESPIRATORY PHYSIOLOGY / PATHOLOGY
Acute respiratory failure / acute lung injury (ALI)
Acute Respiratory Distress Syndrome (ARDS)
Aspiration
Bronchopulmonary infections
Upper airway obstruction
Pulmonary mechanics and gas exchange
Oxygen therapy
Indications & hazards of mechanical ventilation
Barotrauma / volutrauma
Criteria for weaning and weaning techniques
Empyema
Pneumothorax / hemothorax
Respiratory monitoring (airway pressure, intrathoracic pressure, tidal
volume, pulse oximetry, dead space-tidal volume ratio, compliance,
resistance, capnography)
Metabolic monitoring (oxygen consumption, carbon dioxide
production, respiratory quotient)
27
Knowledgeable
& able to teach Knowledgeable
RENAL PHYSIOLOGY / PATHOLOGY
Fluid and electrolyte balance
Prerenal, renal, and postrenal failure
Acid-base disorders and their management
Principles of hemodialysis, continuous veno-venous
hemofiltration (CVVH)
Interpretation of urine electrolytes
Evaluation and treatment of oliguria
Drug dosing in renal failure
Rhabdomyolysis
CNS PHYSIOLOGY / PATHOLOGY
Coma
Metabolic
Traumatic
Drug induced
Perioperative management of neurosurgery patients
Brain death evaluation and certification
Diagnosis / management of persistent vegetative states
Seizure prophylaxis and treatment
Nontraumatic intracranial bleed
CNS brain monitoring (intracranial pressure, cerebral
blood flow, cerebral metabolic rate, EEG, jugular venous
bulb oxygenation, transcranial doppler)
METABOLIC & ENDOCRINE EFFECTS OF CRITICAL
ILLNESS
Enteral nutrition
Parenteral nutrition
Disorders of thyroid function (thyroid storm, myxedema
coma, sick euthyroid syndrome)
Adrenal crisis / insufficiency
Diabetes insipidus
Diabetes mellitus
Hyperglycemic control
Hypoglycemia
Disorders of calcium, magnesium, and phosphate
balance
Learning,
Absent or
Not
but
inadequate Observed
incomplete
28
Knowledgeable
& able to teach Knowledgeable
INFECTIOUS DISEASE PHYSIOLOGY
Antimicrobial agents
Antifungal agents
Anaerobic infections
Systemic Inflammatory Response Syndrome (SIRS)
Severe Sepsis
Use of drotrecogin alfa recombinant (Xigris™)
Hospital acquired and opportunistic infections
Adverse reactions to antimicrobial agents
Acquired Immune Deficiency Syndrome (AIDS)
Infectious risks to health care workers
Evaluation of fever in the ICU patient
Development of antibiotic resistance
Universal Precautions
Isolation and Reverse Isolation
ACUTE HEMATOLOGIC & ONCOLOGIC DISORDERS
Thrombocytopenia / thrombocytopathy
Disseminated intravascular coagulation (DIC)
Anticoagulation; fibrinolytic therapy
Principles of blood component therapy
Platelet transfusion
Packed red blood cells
Fresh frozen plasma
Albumin
Cryoprecipitate
Prophylaxis against thromboembolic disease
Learning,
Absent or
Not
but
inadequate Observed
incomplete
29
Knowledgeable
& able to teach Knowledgeable
GASTROINTESTINAL, GENITOURINARY, & OB/GYN
Acute pancreatitis
Upper GI bleeding including variceal bleeding
Lower GI bleeding
Acute hepatic failure
Toxic megacolon
Acute GI perforation
Ruptured esophagus
Acute inflammatory diseases of the intestine
Acute vascular disorders of the intestine, including
mesenteric infarction
Obstructive uropathy, acute urinary retention
Urinary tract bleeding
Toxemia of pregnancy; amniotic fluid embolism, HELLP
Syndrome
Stress ulcer prophylaxis
Drug dosing in hepatic failure
Acalculous cholecystitis
Post-operative complications including fistulas, wound
infection, and evisceration
ENVIRONMENTAL HAZARDS
Drug overdose and withdrawal
Hyperthermia
Hypothermia
Envenomation
TRAUMA & BURNS
Initial approach to management of multisystem trauma
CNS trauma (brain and spinal cord)
Skeletal trauma including the spine and pelvis
Chest trauma - blunt and penetrating
Smoke inhalation, airway burns
Flail chest, chest trauma, pulmonary contusion
Abdominal trauma - blunt and penetrating
Crush injury
Burns
Electrical injury
PHARMACOKINETICS & DYNAMICS
Uptake, metabolism, and excretion of common drugs (i.e,
aminoglycosides, neuromuscular blockers, sedatives,
analgesics)
Principles of pain management
Learning,
Absent or
Not
but
inadequate Observed
incomplete
30
Knowledgeable
& able to teach Knowledgeable
Learning,
Absent or
Not
but
inadequate Observed
incomplete
PRINCIPLES OF RESEARCH IN CRITICAL ILLNESS
Study design
Biostatistics
Abstract preparation
Manuscript preparation
Prognostic indices, severity and therapeutic intervention
scores
ADMINISTRATIVE & MANAGEMENT PRINCIPLES
Priorities in the care of the critically ill or injured
Collaborative practice principles
Participation in relevant hospital committees
Principles of triage and resource allocation
Clinical practice guidelines
Electronic data base utilization
Use of computers in critical care units
ETHICAL & LEGAL ASPECTS OF CRITICAL CARE
MEDICINE
The ethical decision-making process
Do Not Resuscitate orders
Futile care
Living wills, advance directives, durable power of attorney
Comments
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Faculty Signature: ___________________________________ Date: _______________
31
CRITICAL CARE PROCEDURAL SKILLS
The definition of competency to perform the listed procedures must include knowledge of the indications,
contraindications and complications of these interventions. (Please check the appropriate box)
Knowledgeable
& able to teach
AIRWAY
Maintenance of open airway in non-intubated
patients
Nasotracheal airways
Ambu-bag / mask ventilation
Intubation (oral)
Intubation (nasotracheal)
Cricothyrotomy / tracheostomy
Suction techniques
BREATHING / MECHANICAL VENTILATION
Use of Synchronized Intermittent Mechanical
Ventilation (SIMV)
Use of Pressure Control Ventilation (PCV)
Appropriate use of PEEP
Appropriate application of oxygen therapy
Monitoring of airway pressures
Pressure-volume waveform analysis
Application of end tidal CO2 detectors, pulse
oximetry
Arterial blood gas analysis
Management of pneumothorax (needle, chest tube
insertion)
Fiberoptic laryngotracheobronchoscopy
X-ray interpretation
CIRCULATION
Insertion of monitoring lines
Central venous
Arterial
Pulmonary artery catheter
Interpretation of invasive hemodynamic parameters
Interpretation of 12-lead ECG
Application of vasoactive medications
Cardioversion
Transcutaneous / transvenous pacing
CENTRAL NERVIOUS SYSTEM
Management of intracranial and cerebral perfusion
pressures
GASTROINTESTINAL
Insertion of nasoenteric feeding tubes
Knowledgeable
Learning,
but
incomplete
Absent or
inadequate
Not
Observed
32
Knowledgeable
& able to teach
Knowledgeable
Learning,
but
incomplete
Absent or
inadequate
Not
Observed
HEMATOLOGIC
Appropriate utilization of blood component therapy
Management of massive transfusions including
rapid infusers
Proper ordering and interpretation of coagulation
studies
INFECTIOUS DISEASE
ICU sterility techniques and precautions
Interpretation of blood, sputum, urine, body fluid
cultures
Appropriate use of antimicrobial agents
INTEGUMENT
Use of temporary abdominal closures
Management of intra-abdominal and abdominal
perfusion pressures
MONITORING
Utilization, zeroing, calibration of transducers
Troubleshooting of monitoring equipment
NUTRITION
Use of total parenteral nutrition
Interpretation of metabolic cart and urine urea
nitrogen studies
Comments
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Faculty Signature: ___________________________________ Date: ________________
33
ORLANDO REGIONAL MEDICAL CENTER
DEPARTMENT OF SURGICAL EDUCATION
RESIDENT EVALUATION OF
SURGICAL CRITICAL CARE TEACHING FACULTY 2007 - 2008
Faculty Name:
Instructions: Please evaluate the above faculty member based upon your recent
experiences.
SCALE: 5=Outstanding, 4=Very Good, 3=Good, 2=Fair, 1=Poor
Please rate the faculty member on the following criteria:
5
4
3
2
1
NA
Practices comprehensive patient care addressing all pertinent issues
Provides effective leadership during patient care rounds
Effectively integrates patient care with bedside teaching
Includes the nursing / respiratory therapy staff in decision making
Effectively interacts with families during Family Rounds
Utilizes Evening Checkout Rounds effectively
Serves as a role model for professional / caring interaction with
patients and family members
Integrates ethical considerations in patient care
Provides constructive feedback to residents about their performance
Develops and maintains good rapport with residents
Utilizes the literature to support patient evaluation and management
Actively participates in teaching conferences
Helps resident establish personal and professional goals
Facilitates resident professional development
Encourages resident research and scholarly activities
COMMENTS:
Name of resident (optional):
(continue on back if needed)
34
VIII. DIDACTIC TEACHING CONFERENCES
A significant portion of the teaching within the residency program occurs at the bedside during
morning ICU Rounds as well as during afternoon Family Rounds. The following represents the
didactic teaching conference schedule for the 2007-2008 academic year. All lectures will take
place in the Trauma ICU conference room at 12 noon unless otherwise specified.
Fellow’s Conferences
1st Tuesday
2nd Tuesday
3rd Tuesday
4th Tuesday
5th Tuesday
EBM
RES
PD
RES
EBM
Critical Care Teaching Conferences
1st Wednesday
GR
2nd Wednesday
JC
3rd Wednesday
JTC
4th Wednesday
MM
5th Wednesday
GR
Evidence-Based Medicine Guidelines Conference
Research Conference
Professional Development
Research Conference
Evidence-Based Medicine Guidelines Conference
Critical Care Grand Rounds
Critical Care Journal Club
Joint SCC / MCC Teaching Conference
Critical Care Morbidity and Mortality Conference
Critical Care Grand Rounds
Evidence-Based Medicine Guideline Development (1st and 5th Tuesday)
 Working in conjunction with the attending staff and PharmD, residents are instructed on
and actively participate in the conception, research, formulation, and production of
evidence-based medicine (EBM) patient care guidelines for use in the adult ICU's. These
guidelines are made available to the physician and nursing staff of the corporation
through both SWIFTMD as well as our website, surgicalcriticalcare.net. The intent is to
both improve patient care at Orlando Regional Healthcare (ORH) while also creating a
repository of guidelines that future, current, and past trainees may access for use in their
own ICU's one they leave ORH.
Research Conference (2nd and 4th Tuesday)
 The first of the monthly Research Conferences is a didactic lecture from the faculty
covering a particular aspect of scholarly activity such as study design, biostatistics, data
analysis, abstract and manuscript preparation and submission, or poster and oral
presentation. During the second of the monthly Research Conferences, the status of
both current and future research projects within the department is discussed in a “working
meeting” format. Although greatest emphasis in placed on trainee-initiated research,
education on participation in multi-center, corporate-funded clinical trials is also provided.
Professional Development (3rd Tuesday)
 This conference is intended to provide each resident with the education necessary to
apply for employment in critical care and function effectively post-training in the
administration of an ICU. Topics include time management, writing a curriculum vitae,
the interview process, professional societies and associations, hospital committees,
practice management, billing and coding, clinical documentation, core measures, quality
assurance programs, and legal depositions.
Critical Care Grand Rounds (1st and 5th Wednesday)
 Scholarly lectures from the SCC faculty, visiting professors, and consultant subspecialty
physicians are held monthly to present the breadth of critical care management with an
emphasis on evidence-based medicine and the current state-of-the-art.
35
Journal Club (2nd Wednesday)
 Pertinent recent manuscripts from the various critical care journals are selected by the
ICU faculty and discussed jointly by the faculty and residents. The current state-of-theart is discussed with an eye to altering current practices or revising the department’s
evidence-based medicine guidelines as needed based upon the latest literature.
Joint SCC / MCC Teaching Conference (3rd Wednesday)
 A combined teaching conference is held, attended by the respective faculty and residents
from the Surgical Critical Care (SCC) and Medical Critical Care (MCC) services. Recent
interesting cases are presented by each service and discussed.
Morbidity and Mortality Conference (4th Wednesday)
 While all deaths that occur in the intensive care units are discussed in the weekly
Department of Surgical Education Morbidity and Mortality conference, specific deaths or
complications of particular critical care interest will be presented and discussed in this
setting. Potential cases should be submitted to Dr. Cheatham in advance of the
conference for review.
General Surgery Grand Rounds (Each Friday)
 Each resident is expected to attend the Department of Surgical Education’s Grand
Rounds each Friday morning. The topics rotate between general surgery, trauma /
critical care, colorectal surgery, and tumor board.
General Surgery Morbidity and Mortality Conference (Each Friday)
 The SCC residents are expected to actively participate in the Department of Surgical
Education’s weekly Morbidity and Mortality conference. The residents play an important
role in describing the ICU care provided to patients that are presented in this conference.
36
2007-2008 Critical Care Lecture Series
Date
Thurs, June 28
1:00 PM
7B Conference Room
Fri, June 29
1:00 PM
Med Ed Conference
Room B
Topic
Getting Started in Surgical Critical Care: Part I

Introduction to the SCC fellowship

Hemodynamic Monitoring Principles

Hemodynamic Calculations

Oxygen Transport Calculations

Hemodynamic Monitoring: Today’s Tools in the
ICU
Getting Started in Surgical Critical Care: Part II

Vasoactive Medications

Pulmonary Pathophysiology

Modes of Mechanical Ventilatory Support

Principles of Pharmacology
Responsible Faculty
Dr. Cheatham
Dr. Cheatham
Dr. Cheatham
Dr. Promes
Dr. Gesin
Tues, July 3
EBM: “An Introduction to Evidence-Based Medicine”
Wed, July 4
Holiday - No Conference
Tues, July 10
RES: “The Clinical Research Process”
Dr. Cheatham
Wed, July 11
GR: “Sepsis, Shock, and SIRS”
Dr. Cheatham
Tues, July 17
PD: “Your Future Career in Critical Care”
Dr. Cheatham
Wed, July 18
Joint SCC / MCC Teaching Conference
Faculty
Tues, July 24
RES: “The Institutional Review Board”
Dr. Promes
Wed, July 25
Critical Care Morbidity and Mortality Conference
Dr. Lube
Tues, July 31
EBM: “How to Create an EBM Guideline”
Dr. Lube
Wed, August 1
GR: “Infectious Disease and Antimicrobial Utilization”
Dr. Gesin
Tues, August 7
EBM: Guideline review
Dr. Lube
Wed, August 8
Critical Care Journal Club
Dr. Lube
Tues, August 14
RES: “Submitting an IRB Proposal”
Toby Safcsak
Wed, August 15
Joint SCC / MCC Teaching Conference
Faculty
Tues, August 21
PD: “Time Management”
Dr. Cheatham
Wed, August 22
Critical Care Morbidity and Mortality Conference
Dr. Cheatham
Tues, August 28
RES: “Study Design”
Dr. Cheatham
Wed, August 29
GR: “Fluid Resuscitation: Crystalloid vs. Colloid”
Dr. Cheatham
Tues, September 4
EBM: Guideline review
Dr. Cheatham
Wed, September 5
GR: “Surgical Nutrition”
Dr. Lube
Tues, September 11
RES: “Creating a Research Database”
Dr. Cheatham
Wed, September 12
Critical Care Journal Club
Dr. Lube
Tues, September 18
PD: “Quality Assurance”
Dr. Block
Wed, September 19
Joint SCC / MCC Teaching Conference
Faculty
Tues, September 25
Research Conference
Dr. Cheatham
Wed, September 26
Critical Care Morbidity and Mortality Conference
Dr. Cheatham
Tues, October 2
EBM: Guideline review
Dr. Cheatham
Wed, October 3
GR: ”The Four Compartment Syndromes”
Dr. Cheatham
Tues, October 9
RES: “Statistics I”
Dr. Cheatham
Dr. Cheatham
Wed, October 10
Critical Care Journal Club
Dr. Lube
Tues, October 16
PD: “Writing a Curriculum Vitae”
Dr. Cheatham
37
Wed, October 17
Joint SCC / MCC Teaching Conference
Faculty
Tues, October 23
Research Conference
Dr. Cheatham
Wed, October 24
Critical Care Morbidity and Mortality Conference
Dr. Cheatham
Tues, October 30
EBM: Guideline review
Dr. Cheatham
Wed, October 31
GR: “Acute Renal Failure”
Dr. Block
Tues, November 6
EBM: Guideline review
Dr. Cheatham
Wed, November 7
GR: “Endocrine Response to Injury”
Dr. Lube
Tues, November 13
RES: “Statistics II”
Dr. Cheatham
Wed, November 14
Critical Care Journal Club
Dr. Lube
Tues, November 20
PD: “The Interview Process”
Faculty
Wed, November 21
Joint SCC / MCC Teaching Conference
Faculty
Tues, November 27
Research Conference
Dr. Cheatham
Wed, November 28
Critical Care Morbidity and Mortality Conference
Dr. Cheatham
Tues, December 4
EBM: Guideline review
Dr. Cheatham
Wed, December 5
GR: “Traumatic Brain Injury”
Dr. Lube
Tues, December 11
RES: “Publishing Your Research”
Dr. Cheatham
Wed, December 12
Critical Care Journal Club
Dr. Lube
Tues, December 18
PD: “Core Measures”
Dr. Cheatham
Wed, December 19
Joint SCC / MCC Teaching Conference
Faculty
Tues, December 25
Holiday – No conference
Wed. December 26
Holiday – No conference
Tues, January 1
Holiday – No conference
Wed, January 2
Holiday – No conference
Tues, January 8
RES: “Abstract Preparation”
Dr. Cheatham
Wed, January 9
Critical Care Journal Club
Dr. Lube
Tues, January 15
PD: “Critical Care Billing and Coding”
Dr. Cheatham
Wed, January 16
Joint SCC / MCC Teaching Conference
Faculty
Tues, January 22
Research Conference
Dr. Cheatham
Wed, January 23
Critical Care Morbidity and Mortality Conference
Dr. Cheatham
Tues, January 29
EBM: Guideline review
Dr. Cheatham
Wed, January 30
GR: “Burn Management Update”
Dr. Smith
Tues, February 5
EBM: Guideline review
Dr. Cheatham
Wed, February 6
GR: “ICU Sedation and Analgesia”
Dr. Gesin
Tues, February 12
RES: “Manuscript preparation”
Dr. Cheatham
Wed, February 13
Critical Care Journal Club
Dr. Lube
Tues, February 19
PD: “Trauma Billing and Coding”
Dr. Cheatham
Wed, February 20
Joint SCC / MCC Teaching Conference
Faculty
Tues, February 26
Research Conference
Dr. Cheatham
Wed, February 27
Critical Care Morbidity and Mortality Conference
Dr. Cheatham
Tues, March 4
EBM: Guideline review
Dr. Cheatham
Wed, March 5
GR: TBA
38
Tues, March 11
RES: “The Manuscript Review Process”
Dr. Cheatham
Wed, March 12
Critical Care Journal Club
Dr. Lube
Tues, March 18
PD: “Hospital Committees”
Faculty
Wed, March 19
Joint SCC / MCC Teaching Conference
Faculty
Tues, March 25
Research Conference
Dr. Cheatham
Wed, March 26
Critical Care Morbidity and Mortality Conference
Dr. Cheatham
Tues, April 1
EBM: Guideline review
Dr. Cheatham
Wed, April 2
GR: TBA
Tues, April 8
RES: “Powerpoint Presentations”
Dr. Cheatham
Wed, April 9
Critical Care Journal Club
Dr. Lube
Tues, April 15
PD: “Professional Societies and Associations”
Dr. Cheatham
Wed, April 16
Joint SCC / MCC Teaching Conference
Faculty
Tues, April 22
Research Conference
Dr. Cheatham
Wed, April 23
Critical Care Morbidity and Mortality Conference
Dr. Cheatham
Tues, April 29
EBM: Guideline review
Dr. Cheatham
Wed, April 30
GR: TBA
Tues, May 6
EBM: Guideline review
Wed, May 7
GR: TBA
Tues, May 13
RES: “Poster Presentations”
Dr. Cheatham
Wed, May 14
Critical Care Journal Club
Dr. Lube
Tues, May 20
PD: “Ethics and End of Life”
Dr. Cheatham
Wed, May 21
Joint SCC / MCC Teaching Conference
Faculty
Tues, May 27
Research Conference
Dr. Cheatham
Wed, May 28
Critical Care Morbidity and Mortality Conference
Dr. Cheatham
Tues, June 3
EBM: Guideline review
Dr. Cheatham
Wed, June 4
GR: TBA
Tues, June 10
RES: “Oral Presentations”
Dr. Cheatham
Wed, June 11
Critical Care Journal Club
Dr. Lube
Tues, June 17
PD: “Depositions and Legal Testimony”
Dr. Cheatham
Wed, June 18
Joint SCC / MCC Teaching Conference
Faculty
Tues, June 24
Research Conference
Dr. Cheatham
Wed, June 25
Critical Care Morbidity and Mortality Conference
Dr. Cheatham
Dr. Cheatham
39
IX. SUPERVISION AND DECISION MAKING AUTHORITY - RELATION TO FACULTY,
RESIDENTS, AND MEDICAL STUDENTS
.A good fellow is one who understands how to provide state-of-the-art care to a critically ill
patient. An excellent fellow is one who communicates effectively with those around him/her while
providing the same excellent level of patient care. First and foremost, remember that the patient
belongs to the attending physician and that the final decision and ultimate responsibility for the
patient’s outcome always lies with this surgeon or his/her designee. In the ORMC ICU’s, a
distinction is made between the patient’s “attending” physician and the patient’s “managing”
physician. For some patients, the attending and managing physician will be the same. For
others, in which the attending physician may not feel comfortable directing the critical care
management of the patient, a “managing” physician (usually an intensivist) will be designated by
the attending physician to direct the patient’s day-to-day ICU care. Both the attending and
managing physician may also delegate another physician, the chief or senior resident on the
primary service, or a consulting physician to make specific patient care decisions.
For every patient on the teaching services (Blue or Red) of the Department of Surgical
Education, the SCC service will be designated as the patient’s managing physician. The SCC
service will then make all patient care decisions in conjunction with the patient’s chief surgical
resident. The SCC service will frequently be designated as the managing physician for “private”
general surgical and vascular service patients also. In these cases, the SCC service will manage
the day-to-day ICU care, but ultimate decision making responsibility remains with the patient’s
private surgical attending. The degree of patient care involvement assigned to the SCC service
on these private patients varies from surgical attending to attending. You will come to know each
surgeon’s preferences during your first month or two in the ICU.
All plans, procedures, non-routine physician’s orders and diagnostic tests, consultation requests,
and therapeutic or management changes must be discussed with the primary surgical team
PRIOR to initiation. All adverse occurrences, complications, condition changes, and unexpected
test results must be immediately communicated to the ICU attending and the primary surgical
team as well. Evidence of the communication with the primary surgical team must be
documented in the medical record.
Communication between the SCC service and the primary surgical services should be at the
senior resident, chief resident, or attending level. Unlike on the regular patient care floors,
communication up and down the traditional chain of command beginning with junior level
residents can cause confusion and delay therapy. Communicate with the SENIOR resident as
much as possible.
The Surgical Critical Care service cannot function without
communication and the trust that it fosters.
Both the residents on the primary surgical services and the SCC residents make rounds and
document their patient care activities, assessment, and plans in the patient's medical record as
frequently as is indicated. Thus, two sets of daily patient are notes are generated each day.. The
residents rotating on the SCC service for one to two months are members of the general surgery,
emergency medicine, and internal medicine residency programs. During their rotation, they
receive an intense experience in critical care closely supervised by the SCC attendings and SCC
residents.
The SCC residents enhance the educational experiences of the general surgery and emergency
medicine residents by providing close supervision of junior residents and contributing to the
teaching conferences attended by these residents. They work as peers to the senior and chief
residents in the general surgical program and share in the management of the complex patients
admitted to the critical care units.
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This parallel approach to patient management is intended to improve patient care by making
resident and attending physicians available immediately at all times in the critical care units. The
program is intended to improve educational efforts in critical care by providing an intense
experience for the sponsoring program junior and senior level residents during their rotations on
the SCC service. It also provides continuing experience in critical care for senior level and chief
residents as they round throughout their entire training program with the Surgical ICU attendings
and residents.
You will initially be given responsibility commensurate with your experience and aptitude. As you
mature in your abilities and knowledgebase, clinical responsibility will increase. As an SCC
fellow, you are responsible for daily rounds in the ICU and overseeing the care of patients and
supervision of the residents and medical students on the service. You are responsible for writing
orders, assessing patients, and performing procedures. You will make patient management
decisions with the aid and supervision of the critical care faculty. You will interact with attending
staff from other primary surgical services in reaching clinical strategies and management
decisions in a collaborative process. This teaches the elements of working in an “open unit” ICU
model.
A. Relation to Faculty:
The relationship between faculty and the SCC residents is largely one-on-one with direct
supervision by an individual faculty member assuming responsibility for each and every
patient and each and every patient care decision or procedure. Faculty will be kept
informed at all times of any major change and as such assume responsibility for any
problems or complications that might occur. It is essential that you work closely and
remain in close contact with the ICU attending at all times. This will be one of the most
valuable learning opportunities of your fellowship. In addition, you will develop individual
relationships with each attending on the surgical staff. This includes general surgery,
neurosurgery, vascular, orthopedics, and any other surgical attendings having patients
present in the ICU.
B. Relation to Residents:
SCC residents are to work directly with the general surgery and emergency medicine
residents in a supervisory capacity with the expectation that you not only supervise, but
also teach and educate residents at the junior levels. You will have a collaborative and
complimentary interaction with the chief residents from the primary surgical services,
serving as a consultant to them while they maintain primary responsibility for their patient.
You and the assigned ICU residents will make rounds with the primary teams and
participate in the decision making and provision of care.
C. Relation to Medical Students:
SCC residents are to work closely with the rotating medical and physician’s assistant
students, ensuring that they are supervised in all aspects of the care they provide. You
will teach the medical students and provide impromptu continuous teaching opportunities
directly related to specific patients. You will also be asked to provide informal evaluation
of medical students rotating in the ICU under your supervision, so that a final evaluation
done by the ICU attending is consistent with the overall evaluation of the team.
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X. SCHOLARLY ENVIRONMENT
There is an active scientific research program on the Surgical Critical Care service. Current
areas of particular interest include the use of continuous cardiopulmonary monitoring systems in
the assessment of hemodynamics and oxygen transport in critically ill patients, shock
resuscitation, prevention of organ failure, hyperglycemic control, adrenal insufficiency of critical
illness, and the pathophysiology surrounding intra-abdominal hypertension and abdominal
compartment syndrome.
Each resident is expected to complete a one-month elective research rotation during the
academic year. These is extensive support available for clinical research including computerized
databases, computer support, document processing, information retrieval, and biostatistical
support.
A full-time research coordinator is available to assist in study design and
implementation. During the research elective, the resident will be afforded uninterrupted time to
focus on study design and data analysis. Each resident will be expected to complete at least one
research study during their fellowship and submit this for both presentation at a national critical
care meeting as well as publication in a peer-reviewed journal. Each resident will work under the
direction of a faculty supervisor in achieving these goals.
XI. QUALITY ASSURANCE
The department has a number of programs for quality assurance and performance improvement.
Quality assurance and performance improvement will occur through daily rounds, the weekly
Department of Surgical Education Morbidity and Mortality conference (in which the SCC residents
will be expected to play an active role), the monthly Critical Care Morbidity and Mortality
conference, and data collected for the Intensive Care Information System (ICIS) database.
Complications and deaths are presented at the Department of Surgical Education Morbidity and
Mortality conference with cases presenting complex issues and areas for quality improvement
being presented at the monthly Critical Care Morbidity and Mortality conference. Patient group
specific complication trending (including ICU and hospitals days, ventilator days, infection rates,
and complication rates) is reviewed on a regular basis through the ICIS database. The SCC
resident will be exposed to these quality assurance techniques and participate specifically in the
presentation of cases, the review of problems as they occur, and the development of
performance improvement solutions.
XII. RESIDENT DUTY HOURS AND WORKING ENVIRONMENT POLICY
A. Duty Hours
Duty hours are limited to 80 hours per week averaged over a 4-week period. The duty
hours will be in accordance with the ORMC and ACGME Housestaff Duty Hours and
Working Environment Policies/Procedures.
Through the call scheduling process,
residents will be guaranteed at least one weekend per month off and at least one
complete day out of seven relieved of all clinical responsibilities.
B. Monitoring of Duty Hours
Residents and faculty will be provided copies of the rules pertaining to ACGME
requirements for limited resident duty hours. These rules will be discussed during the
Department of Medical Education orientation meeting at the initiation of the fellowship.
Residents will “clock in” and out upon entering and leaving the hospital to document their
compliance with the resident duty hours policy. These records will be reviewed by the
Program Director on a regular basis assure compliance with ACGME resident duty hour
requirements.
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C. On-Call Activities
Call is “in-house” call. Residents will be on call every third to fourth night (seven to eight
times per month on average) and will go home on the following day by 1 PM (to allow for
attendance at the twice weekly didactic teaching conferences).
D. Moonlighting
Residents in the Surgical Critical Care training program are not allowed to moonlight.
E. Support Services
Sleeping quarters and scrubs are provided by the hospital. The on-campus hospital
library is available at all times and is supplemented by on line access to a great number
of scientific journals. A full function cafeteria is open during hospital hours and available
to house staff during this time.
F. Pay
Salary will be $50,811 per year. In addition, office supplies and equipment needs will be
paid for by the department. The department will also sponsor each resident to participate
in one educational conference per year to present scholarly research.
G. Duty Hours Exception
Residents will be allowed to exceed the 80-hour limit only for educational purposes and if
they document why they stayed (i.e. special case, conference, or need to provide patient
continuity). This will not exceed 10% or 8 hours per week, on average. In the event of
being over, they will make it up subsequently to stay in compliance with the average
overall.
XIII. GRIEVANCE PROCEDURES
Should a resident have a specific grievance, you are encouraged to speak with the program
director immediately so that the issue may be resolved in an expeditious manner. Alternatively,
you may contact the office of Graduate Medical Education to assist with this process and follow
the appropriate procedure.
XIV. MONITORING RESIDENT STRESS AND FATIGUE
Given the stressfulness and complexity of working with critically ill or highly injured patients, the
monitoring of stress and fatigue and the attention to its signs and symptoms is an important
priority for the Department of Surgical Education. Any indication that residents are physically,
psychologically, or personally stressed and/or fatigued will be immediately identified, the resident
will be relieved of all clinical duties, and the faculty will assume all responsibilities of the resident
until this problem can be dealt with. During the evaluation process, the program director will ask
the residents about stress and fatigue. Any resident seeing a colleague or feeling personally
fatigued and/or in a stressful situation is asked to identify this immediately to the program director
or to other faculty members so that this can be identified.