CHSD PICU Rotation for UCSD Pediatric Residents

Welcome to the PICU at Children’s Hospital.  The following is an outline of clinical responsibilities for UCSD pediatric residents, and learning opportunities in the PICU. 

PICU DESCRIPTION

The PICU at CHSD is a 24-30 bed multidisciplinary intensive care unit. The ICU team provides the primary care for all patients. There is an active Cardiovascular Surgical program, Trauma program and Transport program in addition to a wide variety of general pediatric and surgical patients.

The PICU attending staff consists of six board certified pediatric intensivists. In addition, five are also certified in anesthesia. There are many times where there will be two attendings taking care of the PICU patients during the day. The attendings take ICU call in 3 to 5 day blocks. Dr Peterson is the Director of the ICU. There are 8 pediatric critical care fellows, of which 3-4 will be on the clinical service at any given time. The ICU team also has two pediatric critical care nurse practitioners.

The ICU medical team truly functions as a team of caregivers, with no one fellow being designated as the responsible physician for a certain patient. Instead, each day a fellow is designated to be responsible for different areas of patient care. One fellow will be responsible for the ICU patients and one for responding to traumas. Either a fellow or nurse practitioner will be designated as responsible for the patients not located in the ICU as well as another person for transport. You can get a copy of the monthly call schedule from the fellows or our administrative assistant, Evelyn Lizasuain. There is also a board in the ICU that has the daily fellow responsibilities listed. The fellows switch on and off service on Mondays.

UCSD residents rotating through the ICU will be in their second or third year of residency. There are also pediatric residents from the Naval Medical Center.

ROLE OF UCSD HOUSESTAFF

On the first day of your rotation (or immediately prior to your rotation if possible) you must check in with the department administrative assistant, Evelyn Lizasuain. The Critical Care Office is located in the Medical Office Building Suite 115. The phone number is 966-576-5863. You will receive a packet of articles at that time.

Patient Care You will be assigned to a fellow based on your call schedule. You will work closely with that fellow and be directly responsible to that fellow during the days as well as your call nights. The fellow to whom you are assigned may change on a weekly basis depending on the fellow's schedule. There is a resident call schedule in the ICU on pod C. Please put your name, pager number, and program on the schedule. Then fill in your nights of call if they are not already listed.

On call days, you and the fellow will be responsible for management of the ICU patients as well as the new admissions. On the new admissions you are responsible for writing an admission note, and with the fellow's help, the admission orders. You will be responsible for presenting the history, physical examination, differential diagnosis and treatment plan during rounds the next day. For the patients you admit and choose to follow during their ICU course, plan on discussing the patients' interval course, assessment and plan during daily rounds. At any one time, you should follow 3 to 4 of the patients you admit. Choose your patients based on disease process and the goals/objectives of the rotation in order to get a broad exposure to critical care. If one of the patients you have been following is located outside the ICU then you need to write a systems oriented note on that patient prior to rounds.

You are responsible for coming in early to write the daily note on patients you are following. Please make the attending and fellows aware of which patients you are following. If you can not be present for rounds on your patients (clinic, post-call, etc) make sure to discuss the patient with the fellow/attending before leaving the unit and follow-up on their care the next morning.

You should keep a list of patients you follow and write notes on. Turn the list oin to Dr Duthie at the end of the rotation. Please include name and diagnosis.

You must also keep a list of CHETs you go out on and turn it in at the end of the month.

If the fellow you have been assigned to is the trauma fellow then you will also respond to trauma activations. If the fellow is the CHET fellow then you will respond to CHET activations with that fellow.

When a patients' status changes, you MUST immediately inform the ICU fellow and/or attending. You also MUST inform the fellow and/or attending of any proposed changes in plan.

On your continuity clinic day, please let the fellow and attending know that you will be leaving early.

The ICU is a fast paced and busy unit. If you are proactive, interested and available you will have an excellent experience. Seek out the fellows, attendings and nurse practioners to make the most of learning opportunities. You will also find that the nursing staff and respiratory staff are excellent resources for you. Review the goals and objectives of your rotation to help guide patient selection. You should also plan on doing literature searches and reading about your patients.

Call will be in house, averaging every fourth night. There is a calendar for your call schedule in Pod C. In the early part of the year it is best to not be on call with a new first year fellow. Please also plan on being on call 2 weekend days (Saturday or Sunday). When on call you should stick with the fellow, help with admissions and other things as they come up. If there is free time, be proactive and ask the fellow if he/she has time to do mock scenarios with you or discuss the patients in more detail. You will also be able to go on transports with the ALS team or full team.

If there is not a NMC resident doing a transport rotation with the ICU team, you may also participate in transports during the day with the OK of your attending physician.

Evaluation It is the resident's responsibility to make an opportunity to discuss their performance with one of the attendings (choose the one with whom you spent the most time) half way through their rotation.

If you encounter problems or concerns during your rotation you should try to resolve them with the attending on service. If this isn't possible then you should make an appointment with Dr Duthie or an attending of your choice.

You are required to hand in two written history and physicals to Dr. Duthie. These will be evaluated and returned to you. In addition, you will receive a self evaluation which you need to fill out and return by the end of the rotation. The above things must be given to either Dr Duthie by the end of your rotation in order for us to send your evaluation to the residency office. In addition, we will give you a rotation evaluation which we ask you to fill out. It is the only way for us to improve the rotation and for our fellows to get feedback and we value your input.

USUAL DAILY SCHEDULE

PICU rounds will generally start between 08:00 and 09:00, depending on the attending. The team will go to Radiology to review radiographic studies, to the floors and then to the PICU. You will need to arrive early enough to see your patients in the PICU and on the floors, review their clinical course over the last 24 hours, and write appropriate notes on the patients outside of the ICU.

Rounds in the PICU are work and teaching rounds. The nurses present patient data for the last 24 hours (data is collated by the night nurse on a separate rounds sheet) and the attending will write the notes on most patients. Again, plan on seeing your patients before rounds, writing a note and being able to discuss your patients during rounds.

TEACHING IN THE ICU

A majority of teaching will occur at the bedside during rounds and during admissions. This teaching will be one on one between the attending or fellow and the resident.

Attendance at the following conferences is mandatory:

1. Didactic conferences held every Tuesday and Thursday morning. These are held in the Critical Care Office.

2. PICU M and M is held the 2nd Friday of the month at 7:30 am in the Medical Office Building, suite 213.

3. Trauma M and M is held the 3rd Friday of the month at 7:30 am in the Medical Office Building, room 113.

4. CHET M and M is held the first Friday of the month at 7:30 am in the MOB suite 213.

PROCEDURES

At the discretion of the fellow and attending you will have the opportunity to perform procedures during your ICU rotation. The fellows will always have the first chance at doing a procedure. If they (and the attending) are comfortable with the patient's status they may allow you to do certain procedures with their supervision. Noninvasive support of the airway (bag-mask ventilation) is a skill often overlooked with which you should attempt to become more comfortable.

GOALS AND OBJECTIVES OF PICU ROTATION

The number one goal of the PICU rotation is for you to learn how to recognize a child with impending respiratory failure, shock or neurologic insult; how to stabilize the child acutely; and which children require the services of a pediatric ICU. The following is a noncomprehensive list of the major topics you should try to learn while in the ICU. Patient population will obviously determine your exposure to certain of the specific illnesses listed below. With the large number of admissions to the ICU each month and with pertinent reading, you should be exposed to most of the following.

Respiratory Recognition and support of the patient with respiratory distress: Physical examination Use of supplemental oxygen Noninvasive means of respiratory support Interpretation of blood gases Indications for intubation and mechanical ventilation Recognition and support of the patient with respiratory failure: Bag-mask ventilation Equipment necessary for intubation Basic principles of mechanical ventilation End tidal CO2 monitors and pulse oximetry Understanding of basic pathophysiology of common causes of respiratory distress and respiratory failure in the ICU, for example pneumonia, status asthmaticus, ARDS, etc.

Cardiovascular Recognition and acute management of hypovolemic, septic and cardiogenic shock Understand the use of basic cardiac noninvasive and invasive monitors Use of inotropic agents

Neurologic Recognition and management of status epilepticus Differential diagnosis of altered mental status Initial approach to treatment Recognition and acute management of the head injured child Understand basic pathophysiology of the intracranial vault: Cerebral blood flow regulation Cerebral edema Recognition and acute management of increased intracranial pressure ICU management of CNS infections Brain death determination

Fluids, electrolytes, nutrition Differential diagnosis and treatment of common electrolyte abnormalities in the ICU Use of parenteral and enteral nutrition

HELPFUL HINTS FROM ICU STAFF

From Dr Peterson, Director of the ICU:
What we look for in a resident:
1. Enthusiasm
2. Hard work
3. Respect for all members of the ICU team
4. Cheerfulness
5. Care and concern for all patients and their families

From the Business Associates
1. Write legibly and clearly.
2. When an order is written please flag the order by turning the dial to green and place the chart in the bin located at the front of each pod.
3. Charts should be kept in the carousels when not in use.
4. Please date and time all orders. Print and sign your name and list your pager number.
5. When paging someone let the B.A. know whom you paged and where you will be.
6. Please introduce yourself.
7. There are many preprinted order forms in the ICU, including admission orders. Please ask or look for them in the top drawer behind where the BAs sit.

From Social Work
1. All patients and families in the ICU are automatically seen by a social worker.
2. Social workers are available 7 days a week. See the ICU board for the daily schedule.
3. Social workers are involved in family conferences and are very active with families at times of crisis.

From the Pharmacy
1. Date and time all orders. WRITE LEGIBLY. Weight and allergies on admit orders.
2. Write doses in mg/mcg/gram instead of volume.
3. All IV infusion solutions must be reordered daily.
4. Do not include additional zeroes for numbers greater than one. Example: 10 not 10.0 Please include a zero before numbers less than one. Example: 0.1 not .1
5. If you write daily orders during rounds, please check the MAR while writing orders.

From the Respiratory Therapists
1. Get to know the RT's in the ICU. They are an excellent resource.
2. Consult RTs for questions regarding ventilation.
3. Do not extubate a patient without the fellow, nurse and RT in the room.

From the PICU nurses
1. Answer promptly when you are paged.
2. The nursing staff is very knowledgeable about critical care pathophysiology and patient needs. It is to your advantage to work collaboratively with them. Courtesy and mutual respect go a long way!
3. The bedside nurse should be present during daily rounds.
4. Verbal orders are ONLY to be used in an emergency.