VA Medical Intensive Care Unit

Educational Purpose:

The VAICU rotation is designed to expose Internal Medicine residents to a broad range of critically ill patients. The VAICU is a multidisciplinary ICU with a Cardiology attending physician, a Pulmonary/Critical Care attending physician, a Cardiology fellow, a Pulmonary/Critical Care fellow, and three PGY 2 or PGY 3 residents. PGY 1 residents from Anesthesia also participate on the rotation, though they do not take call. Emergency and intensive care of all medical patients in the VA Hospital occur in this setting.

Goal: Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.

Residents are expected to:

PGY 1

PGY 2 and 3

1. To develop bedside physical diagnostic skills and correlate these findings with invasive and noninvasive studies.
2. To understand management of acute events/illnesses, including acute myocardial infarction, acute respiratory failure, sepsis syndromes, acute gastrointestinal bleeding, etc.
3. To enhance medical decision making in the critically ill patient.

Medical Knowledge Goals and Objectives:

Goal: Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care.

Residents are expected to:

PGY 1

PGY 2 and 3

1. To develop bedside physical diagnostic skills and correlate these findings with invasive and noninvasive studies.
2. To understand the indications and contraindications of test ordering and procedures in the ICU setting.
3. To understand management of acute events/illnesses, including acute myocardial infarction, acute respiratory failure, sepsis syndromes, acute gastrointestinal bleeding, etc.
4. To recognize the appropriate use of vasopressor agents, cardiovascular drugs, and antibiotics in the ICU setting.

Practice-Based Learning and Improvement Goals and Objectives:

Goal: Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life long learning.

Residents are expected to develop skills and habits to be able to:

PGY 1

PGY 2 and 3

Systems Based Practice Goals and Objectives:

Goal: Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.

Residents are expected to:

PGY 1

PGY 2 and 3

Professionalism Goals and Objectives:

Goal: Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles.

Residents are expected to demonstrate:

PGY 1

PGY 2 and 3

Interpersonal and Communication Skills Goals and Objectives:

Goal: Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, their families, and professional associates.

Residents are expected to:

PGY 1

PGY 2 and 3

Teaching Methods:

Teaching methods include: bedside teaching on rounds; case-based discussions and didactic sessions, including review of EKG teaching files; review of all appropriate x-rays, EKGs, Swan-Ganz data, weaning parameters, heart catheterizations, and other tests; close supervision and appraisal of medical decision-making.

Mix of Diseases and Pathological Material:

Emergency and intensive care of all types of general medical problems including coronary disease, congestive heart failure, valvular heart disease, arrhythmias, respiratory failure, GI bleeding, pneumonia, sepsis, cerebrovascular accidents, and renal failure.

Patient Characteristics:

Residents care for a diverse patient population with respect to age, ethnicity, and gender. The majority of the patients are older adults, but there are significant numbers of adolescent and young adult patients in some sites. All patients all critically ill, requiring, intensive monitoring and care.

Types of Clinical Encounters:

VAICU patients are admitted from Urgent Care, from VA Primary Care, transferred from the inpatient VA medical services, or transferred in from outside facilities. All patients are initially assessed by the upper level medical resident who performs a history and physical, forms a differential diagnosis, and orders initial diagnostic tests.

Procedures and Services:

• Central venous access
• Swan-Ganz catheter insertion and interpretation
• Endotracheal intubation and ventilator management
• Electrical and pharmacologic cardioversion
• Arterial line placement

Supervision:

Residents on the VAICU service write all orders. They are directly supervised by the Cardiology and Pulmonary/Critical Care fellows as appropriate for an individual patient. The Cardiology and Pulmonary attendings jointly round in the ICU daily and are available for consultation at any time. All procedures are appropriately supervised as well.

Educational Resources to be Used and Reading Lists:

Critical care medicine and general medicine textbooks are available 24 hours a day in the on-site library. On-line journals and Up to Date are also available for 24 hour a day consultation. Teaching rounds including bedside didactic lectures are provided by both the attending and fellow physicians.

Method of Evaluation of Resident Competence:

Residents are evaluated using the global evaluation form by both attendings with input from the respective fellows. Each resident evaluates his or her peers as well. Patient Careis assessed based on direct observation and complete review of all records. Procedural skills are assessed based on direct observation. Medical Knowledge is assessed through direct questioning and observation. Residents are given EKG quizzes as well. Interpersonal Skills and Communication is assessed by observation of interactions with patients and families. The attending physician evaluates Professionalism through direct interaction and observation of the resident Systems-Based Practice is evaluated based on the ability to consult the literature and to improve their performance throughout the rotation. Residents receive formative evaluation throughout the month. The residents evaluate the rotation and the attending physician through the E*Value system. Feedback is given to the attendings and the divisions on an annual basis.