CHOC PICU

Please contact the Rotation Director and Rotation Coordinator at least 4-5 weeks prior to the start of the rotation. Points of contact may be found under Rotation Information.

Please also complete the rotation paperwork below NLT 8 weeks in advance.

CHOC PICU is a tough month, with some really sick kids at times, but you will become much more comfortable dealing with pediatric patients and resuscitations. There are some issues with getting procedures during the block, but this is a moving target and will vary with the time of year and the attendings/fellow(s) with you. 

Check-In

Shoot an email to Dr Knight and Mrs Hernandez prior to the start of the rotation to let them know when you are supposed to be arriving. Mrs Hernandez will send you some resources and required online training. She will also send you a map of the hospital including where to park for the day. After parking, walk across the breezeway from the parking deck to the second deck hospital lobby. You will have a meeting with Mrs Hernandez to fill out some forms and pick up a meal card ($70 limit used in cafeteria or Starbucks) and parking permit (which will allow you to park in the staff lot without buzzing security every time) and you should not need to show up to the PICU before this meeting. During this time, she will have arranged a time at security to get a hospital badge as well, which you need to get into the PICU.

The elevators to get to the PICU (on the 6th deck) are kind of hidden from the main lobby; walk past the first bank of elevators you see, the Starbucks and the cafeteria. There will be a courtyard in front of you and you need to follow that hallway to the right. When you get to an intersection, turn left and walk straight. Take those elevators ahead of you to the 6th floor and go to the left; there will be a set of double doors and use your badge to get access. After going through, head to your right to the nurses' station and the residents hang out there during the day. 

This is all assuming that CHOC PICU is before CHOC anesthesia.

What to Expect

You will be one of 3-5 residents on PICU service, and take 5-7 calls over your 4 weeks at CHOC. Most of the time, the team will be made up of 1-2 CHOC Peds residents, a Navy Peds resident, and maybe a Kaiser EM resident. There will be 1-2 fellows on service as well (either 1 Peds critical care or 2 EM/surgery). You can wear scrubs and a white coat or jacket while on service. There are 14 beds in the PICU, and there may be times when you expand over into the CVICU side of the floor and for the most part, you will not need to worry about that side as there will be a fellow and maybe other residents on the CVICU service. Based upon scheduling, you may or may not have days where you are assigned to the CVICU for rounds; this never happened when I was at CHOC. 

Each resident will carry between 2-4 patients every day, but this can vary depending on how busy the PICU is day to day. Notes are systems based and there is a copy forward option, but you will need to review before signing to make sure there is no incorrect information. For the most part, patients in the PICU will have similar disease processes compared to other places you rotate. There will be patients with asthma exacerbations, bronchiolitis, croup and pneumonia requiring increased respiratory support. There are also a lot of patients with new or poorly controlled diabetes admitted in DKA and requiring an insulin drip; the endocrine service is highly involved and ready to answer questions and there is an inclusive hospital protocol to follow. The PICU works closely with the trauma service and there will be occasional trauma patients admitted for observation. Similar to an adult ICU, there will also be post-neurosurgical patients admitted for observation to the unit as well. Occasionally, there will be patients with bad malignancies and neutropenia with fever as well. Intubated patients will have a chest x-ray everyday unless otherwise specified and there will be changing targets on daily labs depending on the patient and the reason for admission to the PICU.

Arrive at the PICU by 0600 everyday to start pre-rounding, on patients and your daily notes except for the on-call resident, who comes in at 0700. The overnight resident will have assigned patients during their call and will do turnover on your old and maybe new patients after you arrive. I would start my notes for each patient and then touch base with the nurses for other significant events and do a physical exam on each patient. Make sure to note vent settings and drips/rates if applicable to have up to date information in the notes. Make sure you finish your notes prior to starting rounds as the attendings will co-sign them during rounds. In all, I was done with my notes pretty early and would have time to get food or something to drink from the cafeteria or Starbucks. 

Rounds start at 0830 with radiology rounds at the computer by the nurses' station. These are very informal and are designed to review new imaging from the morning or imaging from the new patients overnight. After that, walk rounds start with the patients for the post-call resident, who will leave between 1000 and 1100. At 1100, that resident will sign out all of their to-do items to the on-call resident. The residents will share two computers during rounds to read notes and put in new orders, so there is no need to print progress notes. The attendings rotate to keep things moving along and after the post-call resident leaves, rounds go by room number. In total, rounds usually take 2-3 hours, but it is not unheard of for them to last into the early afternoon depending on the number of patients and their complexity. The attendings and fellows try to do teaching while on rounds, which may make them last longer. During this time, the call resident will pay attention to the patients presented and the to-do list for each patient. The other interns will rotate holding the call phone to accept new patients or call consultants if needed during rounds. On Wednesdays, there were formal radiology rounds in the radiology reading rooms at 0900, but the attendings like to start a little early on those days to get done with at least some of the patients. Weekend rounds are the same, but the attendings like to keep them shorter; there is no conference those days and you are on your own for food.

CHOC has noon conference everyday with free food provided during the lectures; the CHOC Peds residents can show you where to go. The lectures were generally pretty good, but may be hit or miss in terms of their applicability to EM; the food is always good, and free. Every Wednesday, there is a noon conference in the PICU conference room and the attending or fellow will present a topic; this is also accompanied by free sandwiches. 

Afternoons are dedicated to calling consultants, admitting new patients, and transferring/discharging patients from the PICU as well as following up on to-do items. Around 1600, there are afternoon sign-out rounds as a new overnight attending comes on. After these rounds, you finish up any to-do items, sign out to the on-call resident, and the rest of the team leaves for the day.

Call Days

The on-call resident arrives around 0700, but otherwise, things remain unchanged from the other days. The rest of the team should handle admissions from the morning and early afternoon as you will have plenty of admissions overnight to deal with. You spend your day following up on consultants and your to-do list. Try to have at least some peripheral awareness of the other patients on the service and pay attention during rounds. You will assume responsibility for the patients from the post-call resident before they leave in the morning. On the weekend, the other residents will leave after rounds, so you will carry the PICU service for the whole day.

After sign-out rounds, you will be the first call for all of the patients, so take notes during rounds. You will always have a fellow with you on your first call day. The attending and fellow will disappear for a bit to accept turnover from the CVICU side and then generally heads into their call room around the corner from the PICU nurses' station. If you have any issues, feel free to give them a call, but try to avoid knocking on the door. If you get a call about a new patient, you can generally wait for them to get to the floor to see him or her unless they ask for an evaluation from the ED or the floor. There will be cards to fill out from the nurses' station for patient information and basic info about their presenting problem. Give the charge nurse a heads up about any new patients you have accepted. 

When a patient arrives to the floor, do your evaluation and let the fellow know. If the patient is really sick call the attending right away to give a heads up, definitely by the time the patient hit the floor. If there is a fellow, follow your chain of command and call the fellow first; he or she will notify the attending. For a relatively stable patient, you can wait to see the patient, get the story, and then call the fellow/attending, but make sure it’s within the two hour window. Always err on the side of calling the fellow/attending if you have some concern about a patient.

There are overnight rounds around 2300 with the nurses and the attending/fellow. Bring a computer to put in any new orders if necessary, but these are generally short and more for updates than anything else. There is a call room for residents and fellows on the CVICU side of the 6th floor with a lock, but it is pretty far away from the PICU. Ask the fellow or another resident to show you where it is.

Overnight, the nurses are great, polite, and experienced, but CHOC gives them absolutely no autonomy. The nurses WILL come to you, frequently (q5-10 minutes) to input routine orders (replace PIV, d/c foley, renew meds) all the time. CHOC solved this by creating a “non-urgent orders” sheet where nurses can write down any orders that they need and not disrupt patient care by hammering you incessantly and indefinitely.