MICU

MICU (Medical Intensive Care Unit)

Contact Dr. Lief during your first week of MICU to get his compilation of important articles and literature for medical critical care—very helpful as a reference throughout the rotation, especially regarding pressors and ventilators.

Contact prior ED intern to get sign-out on patient list—do this the night before you start the rotation so you get the most updated information on all your patients

MEETING PLACE

5 Greenberg South MICU at 6:30AM at the desks in the main ICU hallway. Sign out is from 6:30AM-7AM. For night, sign out is in the same place, but at 6PM.

CALL SCHEDULE

● Schedules are posted in the Medicine housestaff lounge on the 5th floor or on amion.com (nyhim). Extra copies are available in the M-5 corridor in the Medicine administrative offices. The ED rotator begins off-cycle from the MICU schedule, so the most reliable way to know the schedule is to contact the previous intern and confirm with him or her.

● Make sure that you are not scheduled overnight on the last night leading into another rotation. If you are, contact the chief residents as soon as you receive your schedule.

DAILY SCHEDULE

Pre-round from sign out until attending rounds. Typically handoff from the night team happens between 6-6:30 AM.

Attending rounds begin at 8:30 AM

Evening signout starts at 6 PM.

You’ll be out most days by 7:00 PM

Medicine Chief Residents, Room M-532 (212) 746-4721, pgr 11040, cornellcmr@gmail.com

Dr. Lindsay Lief: liw9021@med.cornell.edu

Description of Rotation: Interns will learn how to manage critically ill medical patients under the supervision of Board Certified/Prepared Intensivists. Interns will become proficient in various aspects of critical care medicine. Some of these areas include ventilator management, management of invasive hemodynamic monitoring, and critical care.

Educational Objectives:

Diagnose and manage common critical care issues (including patients with shock, sepsis, myocardial dysfunction, fluid and electrolyte abnormalities, cardiac arrhythmias, renal failure, hepatic failure, and toxicologic emergencies) based on sound judgment, available evidence, and patient preference (PC, MK, PBL)
Recognize when a patient is unstable requiring immediate intervention (PC)
Prioritize vital critical initial stabilization actions in the resuscitation of a critically ill or injured patient (PC)
Demonstrate knowledge of the physiology of the critically ill patient (MK)
Appropriately utilize medical instrumentation and hemodynamic monitoring in the care of the critically ill patient (PC, MK)
Demonstrate the rational use of laboratory, radiographic, and other diagnostic tests in the care of the critically ill patient based on available evidence and cost effectiveness (PC, MK, PBL, SBP)
Demonstrate the ability to interpret and utilize physiologic and hemodynamic data (PC, MK)
Demonstrate the ability to manage a patient on a ventilator (PC, MK)
Perform medical and invasive critical care procedures (under direct supervision) (PC, MK)
Demonstrate knowledge of dosages, indications, and contraindications for the commonly used vasoactive and critical care pharmacologic agent. (MK)
Demonstrate knowledge of procedural sedation and analgesia and pain control for the critically ill patient (PC, MK)
Demonstrate the appropriate use of consultants in critically ill patients (PC, SBP)
Demonstrate an understanding of the ethical and legal principles applicable to the care of the critically ill patient (PC)
Demonstrate effective use of informational resources, scientific studies and technology to enhance patient care and pursue self improvement and self education (PBL, SBP)
Demonstrate good interpersonal skills among patients, families and professional colleagues (PC, ICS, P)
Always demonstrate respect, compassion, integrity and honesty (P)

KEY: PC – Patient Care; MK – Medical Knowledge; PBL – Practice-Based Learning; ICS – Interpersonal & Communication Skills; P – Professionalism; SBP – System-Based Practice. Please refer to Section VI of this manual for a full description of ACGME’s Core and General Competencies.

Evaluation:

The resident will be evaluated electronically (via the MedHub program) by the supervising attending following his/her four-week rotation in the MICU. The review will be forwarded to the Program Director and will become part of the formal semi-annual resident evaluation process. Immediate problems or areas of concern will be discussed as necessary on a case-by-case basis. The resident will evaluate the rotation via the web-based system. This evaluation will become part of the annual review of the program, which will be reviewed by the Program Director.

Survival Tips:

● Your team consists of 2 interns, 2 residents, a fellow and an attending covering your side (A or B). Often one of the interns or residents will be off and the attendings and fellows will rotate depending on the day. Your resident will be responsible for all 10 patients on the side while you will only have 5. Your resident presents new admissions and you present all the care. There is a sheet available on the MICU website that has a list of the information you are expected to know about each patient on rounds such as drips, vitals, I&Os, antibiotics, code status, rates of pressors, vent settings, etc.... Ask your co-residents to print one out for you. Use this sheet also as a guide for how to present during rounds.

Try to get your notes done prior to rounds by asking the prior intern for the template so that you just have to fill in the blanks in the morning. It will save you a lot of time and help you organize your thoughts/presentation for rounds.

● Rounds begin at about 8:30 AM and are both a planning time and a time for educational discussions. Feel free to ask questions, suggest plans, and discuss fine points of management. ICU is a very precise medicine and they want you to understand all aspects of your patient’s care and do a great job explaining it. Most of the fellows and attendings love to teach and will be happy to have these discussions.

● During rounds, bring one of the mobile computers along and enter orders/write notes/look up information. This will save time. Often if you are presenting the other intern or resident will enter orders that are discussed. You should attempt to do the same for them when you are not presenting.

● After rounds, you will put in any remaining orders, write progress notes, and call or follow up on any needed consults.

● Everything in the MICU requires a physician order, so vented patients need vent orders and restraint orders, nurses will need you to check the “titrate as needed” box for pressor drip orders, etc...Get help from the respiratory tech and other residents on how to put these in.

● Procedures in the MICU often go to the 3rd year residents or the fellows but as an ER rotator you may have more experience with some procedures. Be respectful but you can always ask to participate or perform procedures you feel comfortable performing.

● By the end of the day, you should have the handoff tab updated with a summary of each patient, updated as their dx, status or information changes, and the primary team’s plan to remind you of what is happening. The most important part is the plan for the overnight team—here, you should indicate situational management such as “If X happens, consider doing Y” depending on how the patient has been managed thus far, as well as points such as “Follow up on PM CBC and transfuse if Hb < 7” or “Check midnight ABG and adjust vent settings as needed.” You will also need to order any needed labs for that night, if needed, and for the next day.

● You will sign out to the night team on evening rounds at about 6pm.

● On night shift you will cover all 20 patients from both A and B side and carry out the plans the day team signs out to you. You do not write notes but you will need to update the day team with any changes verbally and update the handoff. Your shift runs from 6pm to 7am.

● There is a MICU manual available from the MICU internal website; ask the residents or attendings to show it to you. While not absolutely necessary for the rotation, it contains some very helpful explanations of various disease processes.

● Pick up medications cards for commonly used ICU meds and antibiotics from the 5th floor pharmacy prior to starting—this includes information on pressors such as starting dosages and concentrations for peripheral vs central lines as well as information on electrolyte repletions which is something we do very little of in the ED and much more on the inpatient end.

● Tarascon Internal Medicine & Critical Care Pocketbook is another good resource.

Readings: Rosen: Chapters 1-7, 118, 132, 199

Marino, The ICU Book: Selected readings (a good general critical care book)

Arbo, Decision Making in Emergency Medicine Critical Care (edited by one of our own!)

Google Sites

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