Welcome to the MICU

1. Welcome to the MICU Uma S. Ayyala

2. Goals & Objectives of MICU Rotation • To become an integral member of an interdisciplinary MICU team consisting of attendings, fellows, residents, medical students, nurses, and respiratory therapists. • To assess and provide basic resuscitative skills to critically ill patients • To initiate mechanical ventilation in critically ill patients

3. Goals & Objectives of MICU rotation • To learn how to manage all forms of shock • To become adept at procedural skills • To improve upon communication skills • To improve upon the synthesis of complex cases

4. Structure of the MICU • 14 bed unit- patients usually from medical services but with surgical overflow • Nursing ratio: 1 nurse for 2 patients. Sometimes 1:1 nursing depending on the pt • One attending for a 1 – 2 week period of time. One daytime fellow, either a 1st or 2nd year fellow. • Overnight- 1 night-time fellow in-house • Respiratory therapist dedicated to the unit.

5. MICU Structure • 6-7 Residents per month, teams of 2-3. Q 3 Call. • On any day, there is a post-call team, on-call team, and a short-call individual. • Each team as a different role on rounds and for the rest of the day. • Rounds begin promptly at 8:00 AM and it is expected that short call will be there by 7:30 AM and the on-call team between 7:30-7:45 AM.

6. MICU Structure • ON-CALL RESIDENTS: • Arrive in the MICU between 7:30-7:45 AM. • Divide up the patients on the board between the 2 of you • Examine patients on rounds. • Responsible for the care of your patients in the ICU as well as your partner’s for the remainder of the day • Responsible for the procedures on the patients • Consults after 5 PM

7. MICU Structure • Post-Call Resident: • Pre-round between 5 AM-8 AM. You are responsible for knowing the events overnight, the trend of vital signs for 24 hours (BP, HR, RR, Tm), the I/O over 24 hours, the ventilator settings and corresponding arterial blood gas. The drips the patients is on- sedatives, pressors, insulin, etc. • After the attending and on-call team examine the patient, the post-call team will present the plan in a systems based fashion.

8. MICU Structure • SHORT-CALL RESIDENT: • Writing the transfer summary, filling out the transfer transition note, and communicating with the MAR and team. Patients are listed at 7:30 AM in the MICU. • Placing and carrying out orders during rounds (using traveling computer). • Assisting in the management of unstable patients especially during rounds. • Joining the fellow in the MICU in evaluating ED consultations and then assisting in any new admissions during the day. • Assisting in any procedures during the day (they will be divided amongst on-call and short call) • THERE IS NO CONTINUITY CLINIC THIS MONTH. WE EXPECT THAT YOU WILL BE THERE TILL AT LEAST 4 PM.

9. MICU Sample Timeline • 5 AM- Post-call team begins their pre-rounding • 6-7 AM- Attending arrives and will do either their own pre-rounding, obtain labs • 7 AM- Daytime fellow arrives. Daytime fellow and attending will obtain sign-out from the night-time fellow. Daytime fellow and attending will look at CXRs. • 7:30 AM- Short call should be here- find out from fellow who should be listed and list with BA (who does it electronically) and MAR. • 7:30-7:45- On-Call team arrives. Divides the board. • 8:00- 11:00 AM- Rounds • 11:00-6 PM- Consults called, procedures performed, work to be done. • 6 PM- Night-float fellow arrives and rounds conducted between two fellows and on-call residents.

10. Fellows

11. Role of the Attending • The MICU is a high-intensity MICU- there is only 1 attending for all patients. The ultimate responsibility for all patients resides with the MICU attending. • The MICU attending will be present physically from 7 AM- sign-out and is on-call throughout the night. Along with the fellow, they make every decision regarding rejection and admission. All rejections and admissions go through them regardless of time.

12. Role of the Fellow • There will be one daytime fellow and one night-time fellow in house. • The daytime fellow will be responsible along with the attending for coordinating rounds, to overseeing patient care and procedures, teaching the residents, and triage in the ED. 7 AM- 6 PM • The night-time fellow will remain in-house, will be responsible for night-time triage with the on-call residents, establishing plans of care for all new admissions, helping with any emergent procedures throughout the night. 6 PM- 7 AM

13. Triage • Medical/surgical evaluations: All consults from dept of medicine during the hours of 7:30- 5 PM will be seen by the MARS team who will decide if the patient needs the MICU. After 5 pm, these consults will be seen by the PGY 2 on-call along with the MICU fellow. The consult will be presented to the attending prior to rejection or admission.

14. TRIAGE • ED evaluations: At all hours of the day, this will be the primary responsibility of the MICU resident and fellow (day or night). Together you will be responsible for evaluating the patient within 30 minutes. The case will be then discussed with the MICU attending and a decision will be made. • Documentation: There is no true consult form filled out unless the ED requests a critical care consult at which time the fellow will write the consult. Instead, you document pt is accepted or patient is not a MICU candidate.

15. TRIAGE • Rejections: All rejections will go through the attending. • At no time will you as a resident make a decision to accept or reject a patient without discussing with the fellow. Not having a bed is not a reason to reject a patient. Not an excuse. We will take care of finding a bed if a patient needs an intensive care unit.

16. Progress Notes • To be written by the post-call or on-call teams daily. There is a typed template to be used. The plan will be systems based. • All notes must be dated, timed and signed clearly • Other forms of documentation: Procedure notes, acute change in clinical status, death note, or documentation of a family meeting.

17. Procedures • Types of procedures: Central venous catheters, arterial lines, shilley catheters, LP, paracentesis, thoracentesis • To be certified for either a TLC, shilley or arterial line, you need 10 lines to have been supervised by a fellow. • You will learn about sterile fashion and how to use the ultrasound for both CVC and arterial lines. • At night, the lines will be supervised by the night fellow. • At NO TIME, will anyone outside of the ICU place a line in a MICU patient. • All CVCs are changed on D 7 and arterial lines, D 10.

18. Orders • During rounds, short-call resident will input orders as we round on each patient using the portable computer. Once orders have been placed, the nurse for that patient must be informed of the order. • Try to group orders together for the sake of the nurses. If something is emergent, you need to communicate with them. • The post-call team is to never input orders after 8 AM. The computer will be manned by the short call resident or long call resident.

19. Nurses • Many have been there for decades. They have a tremendous amount of experience and instinct when it comes to critically ill patients. • You should respect their input on a patient and treat all their concerns seriously. If there is any conflict with a nurse, you will get the fellow who will intervene in the situation. • Keep them informed of the plans on your patients especially if there have been changes since rounds. • If you are going to perform a procedure on their patient, let them know. Similarly, if you are removing something (e.g.line), let them know. • RESPECT THEM. Things will be much easier for you by the months end and the second time around.

20. Families • Often you will be on the front line in terms of speaking to patients’ families. We will work as a team to develop coherent goals of care and support for a family. The attending and fellows will be very involved in communicating with families. • Treat families with compassion. Try to explain things to them in layperson’s terms. • If there is conflict, let the fellow and or attending know immediately. • Try to notify the family in advance if a patient is decompensating.

21. Private Attendings • Often patients have private attendings who have long-term relationships with them. Respect these attendings and communicate with them regarding plans of care or change in clinical status. This is especially important with a death of a patient- call the involved physician regardless of time.

22. Your Education • Sample MICU cases from past 2 weeks: • 27 yo s/p C-section post-op day 5 admitted with high fevers, respiratory distress. • 18 yo with C1 Esterase inhibitor deficiency with multiple bouts of angioedema • 50 yo with st segment elevations- pericarditis and pneumonia, growing Strep Pneumo in his blood. • 79 year old with abd pain, nausea, respiratory failure- lipase 24,000- pancreatitis

23. Your Education • We will provide you with a curriculum, a lecture series on how to manage a critically ill patient including pathophysiology, source control, resuscitation basics, and then the supportive care of an ICU patient. We will provide you with the latest evidence for your understanding. • You will have hours of dedicated time with a fellow and attending who will teach you as a group or one on one. • You will learn not only about how to manage sick patients, but how to communicate with families, the quality issues that are arising in all of medicine, and on how to synthesize complex medical cases in general.

24. Our expectations of you • You show enthusiasm. You do your work but you go the extra step of looking up an article or perhaps reading about a condition and educating your peers at rounds. • You remain engaged in rounds even if it is not your patient. Remember, if your partner leaves the floor, you will be responsible for his or her patients and need to know what is going on with them. • Do not be a passive recipient of information- you will not learn that way. Much of what you learn will be necessary skills for the floor when you are managing sick patients.

25. Other issues • If you are finding someone to cover you (e.g. interviews) you will let the attending and fellow know in advance (more than 1 day- several days) and we would hope for a person who has already done the MICU rotation. It will be mandatory that that person comes to our morning rounds even if they are relieving you later in the day. • Any personal issues you have, difficulties with fellows, colleagues, families, death and dying- the attendings are very approachable and our doors are always open.

26. Ten Things to Remember in the MICU 1.  Examine your patients fully 2.  Infection control – purell, gloves and gowns on EVERYONE, EVERYTIME 3.  Listen to, Communicate with and Respect the Nurses 4.  Communicate to the nurse immediately any new TDS order or change in TDS order 5.  Fill out transfer/handoff sheets before discharge from MICU and communicate with primary team before the patient leaves the unit 6.  Call primary attending or service or both for any patient that dies REGARDLESS of time of day 7.  Alert the surgical service of any changes in post-operative patients in the MICU immediately REGARDLESS of time of day 8.  Never “just” draw a blood or urine culture  - THINK before the fever work up 9.  Never take a consult and utter “we have no beds” 10.Never wait until the morning!!!

27. Helpful Hints for Rounds 1.  Know the CVC - know the days the CVC/A-Line have been in place 2.  Know the Antibiotics and days the ABx have been in place 3.  Know the cultures 4.  Know the IV drips and doses 5.  Know the SBT parameters 6.  Know the sedatives 7.  Know the vent settings 8.  Know the ABG/Lactate 9.  Know the enteral feeds 10.Know the protocols

28. Any Questions? • Email or contact: uma.ayyala@mssm.edu scott.lorin@mssm.edu