ICU

Overview

This rotation takes place in J2 at Stanford 500P. You'll take care of some of the sickest cardiac patients in the world and become comfortable managing mechanical circulatory support!

Contacts

Rotation Directors: Dr. Pai Cole (spaicole@stanford.edu)

CVICU Team Structure

• J2 Team 1: General cardiac surgery, Lung transplant, VV ECMO, Vascular, Thoracic

• J2 Team 2: General cardiac surgery, (Dr Fischbein), Heart transplant, LVAD, VA ECMO, Vascular, Thoracic

• J4 Team 3: Minimally invasive CTS, TEVAR, Off-pump CABG, Myocardial bridge, TAVR or Sub-acute CVICU patients covered on J4 by designated J4 provider and CT surgery attending

• CVICU Attendings: there are 2 attendings on each week (for Team 1 and 2). They work Friday-Thursday.  The attendings round with their respective teams each day, sign out to each-other in the afternoon, and trade off taking home-call for both ICU teams each night.  Most weeks there is a dedicated night attending for Monday nights (see schedule in Bunker)

Monthly Schedule

Throughout the month you will spend time on Team 1 and Team 2 (see definitions below).  We ask that you do not make a change to your team assignment without first discussing with Dr. Pai. 

Most commonly you will have: 8 days off, 2 post-call days, and 5 nights (in a row)

CVICU Educational Series website access: Weekly activities including monthly hour-long lectures will take place every Thursday afternoon. During your rotation, you will have open access to the following ghost account to our CVICU Educational Series website to view all past lectures along with additional resources! Please use this account to supplement your rotation, and remember to logout after each use.

Website: https://learnmed.stanford.edu/

Login: laurenmedcvicu@gmail.com

Password: j2500pasteur

Below you will find some pertinent info for workflow in the CVICU.  You will be working with APP’s who can help you navigate the unit as well.  A lot of this information is located in our work-room or “Bunker.”  All of the smart phrases we use will be shared with you in Epic.  Please take a few minutes to read through all of the information below.

Daily Schedule

• 0600-0630: Sign-out

• 0630-0800: Pre-round, see patients, talk with bedside RN. Run-list with CT Surgery chief

• 0800-1030: Rounding with ICU attending

• 1030: ICU multidisciplinary rounds (our ICU attending usually attends—all days EXCEPT Mondays)

• 1030-1400: Confirm all orders placed, Perform necessary procedures, call consults, notes, follow-up AM plans

• 1300-1400: MONDAY ONLY: Multidisciplinary rounds w/emphasis on ECMO and Long LOS Patients (D2 conference room—all providers should attend when able)

• 1400-1800: Admissions from OR, finishing notes, following up plans/tasks/goals from AM rounds. Updating sign-out. Make the patient assignment for night team.

• 1800-1830: Evening sign-out

• 1900-2000: Rounding with night staff and overnight attending. Typically, the attending on call will round individually with the overnight staff members to see all the patients and confirm the overnight plan/goals

• 0400-0600: The night providers should view all AM laboratory and radiographic studies as soon as they are available and make the patient assignment for the day team

Overview

This rotation takes place in Stanford 500P (4th floor) and 300P (E2). You'll be working with IM and EM residents/fellows while taking care of patients with significant medical co-morbidities + carrying the airway pager (see "Airway Pager" section within the Useful page for more information)

Contacts

Rotation Directors: Dr. An Diem La (andla@stanford.edu)

Schedules

WEEKDAY SCHEDULE

• 6am – 8am: Get sign out from the overnight resident, pre-round on patients

• 8:30am – 10:30am: Bedside rounds with attending. You will start with any PAMF patients (because they are staffed separately by a PAMF attending).

• 10:30 – 12pm: Work time (procedures, consults, notes, etc.)

• 12:30-1pm: on MWF there is a resident lecture, often there Tuesday lectures and you will be notified beforehand.

• 1pm – 6pm: Work time

• 6pm: Night resident arrives and takes sign out, you may leave once you have signed out your patients

WEEKEND SCHEDULE

• The weekend tends to be less well-staffed than weekdays.

• You should still arrive at 6am to get sign-out and pre-round.

• There are no 8AM teaching sessions, rounds begin at 8am.

• On Saturdays, one resident (never interns) will be on a 24h shift. Once you finish your work and if things are relatively calm, you may be able to sign out to the covering resident earlier than 6PM.

RESIDENT (R2-R3) RESPONSIBILITIES

• On Sunday-Friday, all residents stay until 6PM to sign out to the night resident

• On Saturdays, one resident will be on 24-hour call – each resident will be expected to take one 24-hour call during the month

• During the call day, you will function as a normal day-time resident carrying a list of patients on the service and taking new admits.

• In the afternoon on 24-hour call, once co-residents have completed work and so long as there are not multiple simultaneous admissions in process, your co-residents may sign out to you before 6PM and leave earlier.

• There is always an ICU fellow in-house overnight.

• On your post-call morning, you will sign out your patients to the incoming day team at 6AM and then may leave – you will not be expected to stay and present any patients admitted overnight.

• There is a call room in E2 with bunk beds for both the Blue and Green Resident.

• See MICU Blue/Yellow Night Resident section below for more detailed description of this responsibility.

DAYS OFF

• You should expect to have 6 days off during their MICU rotation (your IM and EM colleagues will have 5, but an extra day is given to anesthesia residents since we hold the responsibility of carrying the airway pager during many days/nights)

Overview

This rotation takes place in Stanford 500P (K4). You'll rotate with a team of surgical attendings, fellows, and residents + EM residents and learn to manage complex trauma and peri-op resuscitation.

Contacts

Rotation Director: David Spain (dspain@stanford.edu)

Logistics

"We meet in the SICU team room by K444 at 6am for morning sign out and 6pm for evening sign out.

The day team should plan on being around from 6am - ~6pm every day; however, if things are slower, people can absolutely go home early. In return, if there is still a ton going on at 6pm, we would ask that you stay until things settle down and the night person can take over.

There will be a night R2 on from 6pm to 6am. They will round with the on-call senior after sign out. The on-call senior will be available to assist by phone or to come in if necessary.

We are a closed ICU, meaning we are the primary team for all our patients, we actively make decisions, put in orders, call consults, etc. for all of our patients. That being said, we manage our patients closely with their primary surgical team. This is particularly true for transplant, HPB, and surg onc patients. We stay in communication with these teams throughout the day and often throughout the night. We’ll help guide you as to which patients require this level of communication.

There is a SICU triage resident phone that is held by a junior during the day and held by the R2 at night. We can talk about whether juniors would rather log into Voalte and assign themselves to patients versus having all communication go through the SICU phone. I don’t have strong feelings about this and there are arguments for both.

I promise we are a kind, friendly group of people and you should never feel hesitant or afraid to ask questions, call a senior, ask for help with a procedure, wake up someone in the middle of the night if you need help. Err on the side of more communication, it allows us to back up your decisions, and it is often helpful just to talk things out. That being said, if you have having issues with the way people are treating you, let me know so we can address it quickly."

Rounds: You will each be assigned several patients on Monday morning, anywhere from 1-6 patients. Please be ready to round by 0800. You will need to know their numbers, have seen the patient, spoken to their nurse, and come up with your assessment and plan for them. 

Overview

This rotation takes place at the VA Palo Alto. You will rotate through a hybrid medical-surgical ICU and get the full breadth of ICU experience while taking care of our country's veterans.

Contacts

Rotation Director: Margaret Neff (mneff@stanford.edu)

Logistics

Some days you’ll be * (aka "Late resident"), other days will be regular days.  * days mean you’ll stay and help with signout.  Non-* days you’ll stay through 3pm rounds then can plan to leave.   On occasion if we’re overstaffed, I’ll list you as available for triage (meaning you’d do ICU consults and go to eTeams/codes with the fellows).  I don’t have you as * every day you’re there because otherwise it’s a lot of long days!  On * days, arrive by 7am for signout from the night resident/NP and plan to be done approx. 7:30-8:00p (depending on length of night signout).  For days you’re not *,  arrive at 7am to get signout and preround (rounds are at 9:00am).  On those days you can leave after 3pm rounds and once patients are tucked (usually non-* folks leave by 5ish).

When you’re * or on at night here are a few guidelines, in particular with regard to intern oversight and communication with the surgical teams:

• The “Batphone” stays with you or the NP (not with the intern)

• Communication with the surgeons is through you, the NP, or the fellow

• At night it’s best if you either stay up together or grab sleep at the same time (if the service is light); if the intern is left on the unit alone (you’re off the unit or resting), be super clear that they need to call you for anything not previously discussed

• What we’re trying to avoid is too much temptation for the intern to be making independent decisions at night without waking you up.  

• After 7pm rounds, touch base with the surgical chiefs on active patients to establish plans and call criteria for the night;  Know what they want to hear about and error on the sound of over-informing; otherwise they’re surprised in the morning and having to catch up and/or justify decisions to their attendings.  Also the surgical teams know details about the OR case as well as specifics for the patient that are important to incorporate into the plan.

• After night call, be on the unit between 6-7am to be available to touch base with the surgical chiefs as they round prior to the OR.