Detailed CICU Orientation

The majority of patients you will be exposed to will present with an acute coronary syndrome (ACS) including myocardial infarctions (MIs) as well as patients suffering primarily from valvular heart disease, cardiac arrhythmias, chronic congestive heart failure and cardiomyopathies. During the rotation there will be frequent exposure to both indications and contraindications for fibrinolytic therapy, interventional reperfusion therapy. The reasoning behind the rationale for use of beta blockers, Aspirin, Heparins, angiotensin converting enzyme inhibition and lipid lowering therapy in the patient diagnosed with an ACS will also be explored. A working knowledge of anti-arrhythmics and inotropic therapy will also be gained. Significant exposure to mechanical ventilation is to be expected; as well as exposure in certain instances to hemodynamic monitoring by pulmonary artery catheters, intra-aortic balloon pump (IABP) therapy, and temporary pacemaker therapy. 

You will further develop time management and prioritization skills, and learn to efficiently and effectively assess the critically ill patient. 

FOR THE CICU TEAM TO FUNCTION EFFICIENTLY & SAFELY, ALL PAGES, PARTICULARLY CODE PAGES, MUST BE ANSWERED PROMPTLY.  

Typically, through the CICU rotation, there will be a 1-2 seniors (Cardiology, Anesthesia, Emergency, General Internal Medicine, and Cardiovascular Surgery), 4 juniors, and possibly 1-2 students. Intermittently, there will be AIMGs joining the CICU team for an observational period. 

1. Senior Resident: The senior resident numbers are variable and not guaranteed. The Monday to Friday daytime duties of the senior will vary depending on their program of origin and experience: 

• • Anesthesia and Emergency Medicine residents are expected to spend the majority of their time with the CICU team organizing and assisting with the management of more complex patients and coordinating the consult service. 

  • Senior Cardiology residents completing their RAH CICU rotation are expected to spend their time in CICU and on consults; however, they may be able to spend time in the catheterization, stress, and echocardiography laboratories, for example, and also follow their own ‘adopted’ patients. 

  • Senior residents are required to present a case-based group presentation on the fourth Thursday of their rotation. The topic should be decided upon by the end of the second week and the content and relevance can be reviewed with the Attending Cardiologist. By the third Wednesday, notify Cheryl Dixon (cheryl.dixon@albertahealthservices.ca ) and the CICU Attending Cardiologist of the presentation title

  • Senior Residents are second call on weeknights and weekends/holidays

2. Junior Resident: Junior residents divide the daily activity schedule into four different areas: 

• CCU/ ER: The Junior Resident assigned to be on call will receive the majority of daytime consult requests, which can be divided amongst the other residents at the Senior Resident’s direction. 

• This resident is responsible for consults coming from the ER during the daytime and then is responsible for the whole hospital during the night. The most important phone call received is a patient who is in the ER presenting with a suspected ST elevation myocardial infarction (STEMI) and the attending physician is assessing which treatment modality to implement. The current trend in acute myocardial infarction (AMI) is towards emergent angiography and primary percutaneous coronary intervention when appropriate. This applies to large, high-risk MIs, cardiogenic shock associated with MI, and most MIs presenting during regular catheterization laboratory hours. Due to the time delays for staff returning during ‘off hours’, fibrinolysis is most often considered at these times. These patients need to been seen and assessed promptly. During evening and night, CICU is the primary responsibility of the junior resident. Although many things (ie. electrolyte imbalances and anticoagulation) are set up to be managed as per protocol, issues/concerns do arise and your attention to the concerns of the CICU bedside nurse helps ensure holistic management of the patient, as well as support teamwork skills. The resident must maintain timely communication with the nurse in charge to inform them of admission or possible admissions so that staffing can be adjusted to the acuity of the CICU. 

• Junior Residents are first call 24/7

THE POST CALL RESIDENT, PRIOR TO LEAVING, MUST ENSURE THAT THE SENIOR RESIDENT IS AWARE OF ANY OUTSTANDING ISSUES FROM THE PREVIOUS NIGHT. 

• Post-Call: This resident is required to stay for rounds following call, including the last day of the rotation. As per PARA, the resident needs to complete all responsibilities and follow-up so that he/she functions in accordance with the PARA Agreement

  • Call Duties: Junior resident call can be a very busy time during the CICU rotation (1:4 in house calls); additionally it can be one of the most beneficial and educational components of the rotation. During call, the resident will learn to assess and treat acutely ill patients in a tertiary care centre and learn to prioritize actions when multiple requests are encountered. The junior resident is supported by both senior residents and attending staff. Before calling either of the aforementioned physicians, the junior resident should have assessed the case in appropriate detail to convey first an idea of the suspected diagnosis, followed by the important details of the case and, finally, a planned course of action. Timely presentations are necessary to allow efficient implementation of further strategies, if required. Further details regarding call will be discussed during orientation. 

3. Medical Students: Students usually spend one to three weeks on the Cardiology service. The main focus will be in the CICU where the students will be involved in seeing patients and on the consult service. They may assume a CICU patient and follow them with a junior or senior resident. Students are also encouraged to stay at least one evening during the week to shadow the junior resident.