ICU

• IM Chief Orientation PPT to Fam Med: Very helpful review of core topics to expect

• AICU Intern Orientation v5.pdf - an introduction/overview from The Department of Medicine.

• Virtual MICU from CUMC: http://columbiamedicine.org/education/clinical/r_micu.shtml - Contains lectures, articles, etc. Username:residents Password: milstein

• The Little ICU Book: HIGHLY recommended, especially for info on pressors, vents, sepsis 

• NEJM Chief Resident Blog with sentinel articles and MICU orientation

• The critical care handbook from BU is great! ESP for quick review of different medication used in ICU (print those sheets): 

http://www.bumc.bu.edu/im-residency/files/2010/10/Residents-Critical-Care-Handbook.pdf 

• • Analgosedation: Sedation-In service. 7.19.16 (4).pptx

  • Sepsis: Surviving Sepsis Guide.pdf,     Steroid Use in Sepsis_JAMA.pdf,       new sepsis definitions.pdf

  • Vents/ARDsnet Card: Ventilator Protocol Card.pdf

  • Shock/Pressors: SHOCKandPRESSORS.pptx 

  • Declaring Death  

ICU Schedule 2024 (January -June) 

Schedule/Responsibilities

• Find your On Call dates on Amion.com using the passphrase: milstein

• Ensure above correlates with schedule on rotation schedule google doc above

• Ensure your clinic schedule (orange schedule and epic) correlates with rotation schedule google doc above

• Refer to manual.nypmed.org using username: guest and password: milstein

SCHEDULE: Allen ICU is a rotating q4 day schedule of short call, long call, post-call, and OFF days. You will see on the google schedule that sometimes clinic will be scheduled on a post-call day and sometimes on an 'off' day.  Regardless, each week you are guaranteed a minimum of 24hr completely off as highlighted in 'green' on the google doc. 

ON ALL DAYS: Resident table rounds begin at ~7:30am. Rounds with attendings starts at 8:30 or 9am and will last until about 12 noon. You are expected to attend noon conference with the team unless you are in clinic or there is an emergency in the unit.

LONG-CALL DAYS: Arrive at around 7 AM for sign-out. Review all of the completed xrays and assess if the ET tube needs to be adjusted (ask one of the medicine interns to help you assess if unsure). This day you will start by entering all of the labs for the patients for the following day as indicated in the handout under action list. Be cautious about the date of order for Labs, Xray's, and EKGs. You also will be responsible for all needed repletions so keep an eye out for labs resulting (N.B. These repletions and lab orders sometimes fall to the Post-Call Intern). All changes in care should be reported to you throughout the day as you will be responsible for giving updates the following morning on rounds. You take admissions until 7:00 PM and then you have one hour for sign out from 8:00pm until 9:00pm, though it may take less time. You may take a cab home if you leave after 9pm, with up to $10 reimbursement from the department if you submit your receipts.

POST-CALL DAYS:  Arrive at 6am. Pre-round on all patients and write progress notes, and have your task list ready by 7:45 am for resident table rounds. You present all the patients you admitted while on call the previous day during attending rounds, you also present all patients on walk rounds. Formal presentations are expected inclusive of 24 hour events, Subjective, Objective including vitals, changes in physical exam, medications including dose of pressors, and trends in labs, and assesssment/plan.  After rounds, you complete the task list along with the help of the senior and med students. 

START DATES: You are off-cycle from the Internal Medicine interns so they may offer great guidance. If you have any questions prior to starting, you can speak with the IM Allen chief resident and/or Dr. Ekanadham. Dr. Ekanadham will ensure a brief online orientation with the IM chief residents prior to the start of your rotation. 

You can wear scrubs all day, any day in the ICU.

Long Call

• ~ 7 AM - 8 PM

• Pre Round

• Take Primary Responsibility for Task List

• Dismiss Post Call Intern

• Admit Patients

Post Call

• ~ 6 AM - Dismissal

• Follow Up Tasks

  • Trips

  • Transfer Summaries

  • Procedures

  • Repletions

  • AM Labs

How to fulfill responsibilities

• When you place orders that require a callback number and name of physician - just put ICU Intern and 932-4124.

• Ensure all patients have AM labs ordered

• Ensure electrolytes are repleted before you go.

• Update Handoff as you go - hospital course box.

• Take primary responsibilities for task list

  1. • 1. 1. Have daily task list made and be ready to run this list with the On Call Senior by the time the team finishes rounding.

          2. Delegate tasks

          3. Prioritize consults, repletions, studies, procedures

     • Dismiss post call intern

       1. Try to give a finite number of important must-do tasks to the Post Call Intern

       2. Stay on top of these tasks so you can dismiss the Post Call Intern as soon as they are done

• Get Sign Out From Night Person

• Finish Note Before Rounds

• Review plan with On Call Senior Before Rounds (usually, Senior will come in before rounds and run the list)

• Check the daily task list

• Try your best to support the Long Call Intern

• Write the Transfer Summary

• Page the accepting team for Sign Out

• Sign Out to the Accepting Team

• Write the Transfer Patient order

ICU SURVIVAL TIPS

1. Learn how to read ABGs and Modify Vent Settings

2. Learn about pressors and what to start and why

3. walk round on critically ill/hemodynamically unstable patients frequently!

4. Use your resources- nurses, respiratory therapists and medical students are extremely helpful

Post Call Responsibilities: MAINLY: Notes, transfers, presentations, and scut; little to no order writing or large medical decision making on this day.

1. Arrive at 6 am, print signout for yourself, get NF signout

2. round on patients so that you're ready to present at attending rounds: look at lab trends, microbio results, consultant notes, vitals, I/Os, see the pt and do a focused physical exam. Have an assessment and plan ready.

3. AM resident table rounds at ~7:30: post call intern presents 24 hour/overnight events to the other intern, senior resident, and med students

4.  Attending rounds from ~8:30-?; post call intern presents all of the patients in a more formal way.  You will likely look at lab trends, CXRs together. 

5. After attending rounds is team list-run: make scut list with trips, procedures, calls, and transfer "packages"; this list stays on center table and the work is divided among post-call intern and medical students who are post call.

     *trips: anytime a pt leaves the unit, an MD must accompany said patient; this includes field trips to Milstein

     *procedures: all procedures go to post-call intern.

     *calls: consults, family discussions; on-call intern sometimes helps with this

     *packages: 1. tell unit clerk pt is leaving, what kind of bed they need (isolation, dialysis); 2. write transfer summary; 3. once clerk or RN tells you pt has a bed, page hospitalists and sign out patient; 4. review the orders so that the accepting team can easily conduct the transfer documentation.

(NOTE: most "scut list" items can be performed by a medical student. The on-call person's list is more heavily laden with order entry type things).

6. Ensure that everything is done on scut list (don't forget your notes) and a-la-casa yourself! This can happen very early depending on how many pts there are. It's also nice to help the On call intern if overwhelmed.

7. Write your notes.  This can be done before rounds or at the end of the day.  Ask your fellow interns what template they are using to write notes, and try to all use the same template so you can easily refer from past notes. 

On Call Responsibilities: MAINLY: Orders and Admissions; only notes you write are admission notes!

1. Arrive at 7 am

2.Write down CXR readings (however, you'll likely look at them during Attending rounds together)

3.Check AM labs.  Replete electrolytes if necessary.  Don't forget to correct calcium for albumin. 

4. Order labs (PM for today and AM for tomorrow), Tomorrow's EKG and CXR. Order mixed venous 02 for pts with central venous line. Order ABG and CXR for intubated pts. Order Type and Screen for M-W-F mornings (if on call on S-Tu-Th).  Order ionized calcium for any patient on CVVH.  Remember to order PM labs earlier rather than later, the day can get pretty busy.  The rest of the orders can be done later if you don't have time. 

5. reorder 1:1 and/or restraints; then email Dr. Neuberg about which pts required these interventions- this needs to be done both AM and PM. 

6. Attending rounds ~8:30--?  You will do PEs on all the patients with the attending because you are the one taking care of them for the day. 

7. Team list run: lead the team list run and create scut list for post-call and your own to-do list: mostly medication changes, family phone calls, labs.

8. Admit patients: write admission note, put in orders.  Remember to put in vent orders if patient's are intubated or on BiPAP. 

9. Help short call with the scut list.

10. Check PM labs on everybody. Replete electrolytes if necessary. Don't forget to correct calcium for albumin.

11. Read EKGs on patients, comparing to old EKGs and send troponins if evidence of ischemia.  Notify senior if there is any evidence of ischemia.

12.At ~7pm check vitals, ins and outs on all patients.

13.Update handoff and note events on all patients for sign-out in AM. Make to do list for day and night teams.  The handoff should contain the days events by systems, antibiotic updates, pertinent labs/studies, and microbiology. 

14. Round with hospitalist and night float at 8:30pm... then a-la-casa!

Helpful TIPS to think about before the rotation begins:

1) Think about purchasing The ICU Book (the mini version is much less expensive and will be a great guide to the rotation as well as the wards)

2) Review your acid-bases, and how to read an ABG

3) For vent settings remember this simple breakdown:

     Ventilation: determined by tidal volume and respiratory rate

        Oxygenation: determined by FIO2 and PEEP

4) Review your pressors and what receptors they act upon (alpha, beta, etc)

5) Carry a copy of the ACLS Code Cards, you will always have help but it may not be there right away. 

6) Remember your ABCs

You can wear scrubs all day, any day in the ICU.

Rotation Feedback and Evaluation:

1. Please check in with Dr. Ekanadham over text, phone, or email during the last week of the rotation  to discuss any concerns or changes to the rotation.  She will also be checking in with ICU leadership serially to ensure your progress

2. As stated above in the expectations, please seek feedback from attendings that you work with. 

3. As stated above, the goals of this rotation are to gain exposure to ICU level care, not to be a critical care expert or to be someone who can independently place art lines and central lines. As long as you are meeting the expectations laid out above, you are in good shape.