1. Welcome to the TLC! (last updated August 2012)

2. TLC Teams Attending (change weekly on Monday) Fellow (change monthly on the first) 2 Residents, typically from Anesthesia, Internal Medicine, or Emergency Medicine 2-3 Interns, typically from Anesthesia, IM, EM, OB/GYN, ENT, or Orthopedics Occasionally 4th year medical students

3. TLC Organization Critical Care Service (CCS) is comprised of two Medical ICU teams. Most patients will be in the TLC but some “board” in Burn Unit (B4/3), CCU (F4/M5), and NICU (F8/4). TLC is typically the primary service for their patients. – We often serve as the primary service on Orthopedic and OBGYN. – SICU, Vascular Surgery, Transplant Surgery admit to surgical ICU service which is separate from TLC – ICU is a multi-disciplinary field (doctors, nurses, pharmacists, nutritionists, respiratory therapists, physical therapy, occupational therapy).

4. TLC Staff Dr. Wells (TLC Director) Dr. Coursin Dr. Denlinger Dr. Ehlenbach Dr. Hammel Dr. Jarjour Dr. Ketzler Dr. Lingenfelter Dr. Maki Dr. Regan Dr. Runo Dr. Sandbo Dr. Sonetti Dr. Hollatz Dr. Goss Dr. Leibel

5. Daily Schedule 7:00 a.m. (at the latest) – Arrive and round on your patients. 8:00 a.m. – X-ray rounds in the radiology conference room. – Resident gives a one-sentence summary of case before the fellow interprets the film. 8:30 a.m. – Team Rounds – 1-2 computers per team for order-entry and data acquisition. Nurses start rounds – Gives subjectives, vitals, drips ect. – Present your patients (and sometimes your co-resident’s patients) to the team. One sentence summary of patient, s ystem-based Assessment & Plan All team members need to know about all patients, so keep extraneous work and conversation to a minimum.

6. Daily Schedule 11:30 a.m.-4:30 p.m. – Daily work (new admits, follow-up tests, call consults, etc.). 4:30 p.m. – Afternoon rounds with the on-call team followed by intern-to-intern and senior-to- senior sign-out. 7:00 p.m. – On-call intern arrives and receives check-out. 9:00 p.m. – Evening rounds with fellow, residents, and charge nurses.

7. Paperwork All new admits and transfers need new orders. – “IP-Intensive Care-Adult-Admission”

8. Admissions Attending physician is called for transfers from outside facilities. Fellow is called for transfers from the floor and admissions from the ED. Patient placement coordinated by sending and accepting physicians, nursing manager, and charge nurses. Each patient will have a primary resident. – Typically, both the senior and intern should be helping with the admission of every patient (notes, orders, procedures, talking to families, etc.). On call days, all team members may get new patients, whether or not they are on night call.

9. Orders During rounds, one resident should be entering orders. Verbal and telephone orders are for emergencies only. Communicate with the nurse, pharmacist, HUC, etc. as much as possible. Be thoughtful regarding orders. – Not every patient needs every lab test every day. – Few vent changes require an ABG. Order stats only when necessary. Before leaving, make sure your patients have appropriate a.m. orders.

10. Procedures Safety is the primary concern. – Person performing will be determined at the discretion of the fellow (and ultimately, the attending). Consent is mandatory (except for emergent procedures). Nurses should be informed ahead of time for planned procedures. Nurses have a checklist to ensure sterile technique used for central lines. Sterile technique should be used for arterial lines (waterproof, sterile gown will protect you as well as the patient). All invasive procedures require a standard procedure note. NEJM.org has a series of very helpful instructional videos for our common procedures. Wash your hands!

11. Procedure Carts In supply room. Needs to be returned in order to be re-stocked.

12. Ultrasound Two machines in storage room (across from supply room). When done clean, return, and plug in.

13. Transfers to Floor / Discharges To transfer a patient out of the TLC, they need to be accepted by another service. – Accepting service writes orders. Anyone in ICU longer than 72 hours needs a transfer summary. Discharge summary is the responsibility of primary resident. – Needed for deaths as well as discharges. – Be sure to include letter to primary, and referring physicians.

14. Nursing Most nurses have more ICU experience than graduating critical care fellows. Reliable source of information about patients in particular and ICU in general. Able to monitor minute-to-minute changes in patients status. Must be present during rounds – find them! If a nurse questions an order or contacts you because of a patient change, take their concerns very seriously. Two Care Team leaders each shift in TLC (one triage, one staffing).

15. Respiratory Therapy Respiratory Therapists are in charge of all ventilators and O 2 equipment. They assist formation and implementation of respiratory treatment decisions including intubations, extubations, and codes. Only the respiratory therapists may make physical ventilator changes. Residents place the order.

16. Pharmacists Pharmacists staff the TLC 24/7 and are an invaluable asset for medication-related issues. On weekdays, there are two daytime pharmacists and one will typically round with each team.

17. Social Worker Tracy Ryan is the TLC social worker. Very helpful regarding issues such as difficult family dynamics and healthcare power of attorney issues and are a valuable resource for the families.

18. Nutrition There are several nutritionists working in the TLC. Available for consultation and are often on rounds.

19. Families Those working in the ICU are acclimated to the critically ill, but for most patients and families, the ICU is unfamiliar and frightening. Keep families updated. When families are frustrated or hostile, allow the fellow or attending to speak with them to avoid mixed messages. Have a low threshold for involving your fellow, attending, and social worker in family communication.

20. Miscellaneous No eating or drinking in TLC. Follow isolation rules. ICU is very different from most medicine rotations. If you have a question… ask it! If you need help… ask for it! A very dark sense of humor is a common side effect of ICU work… be careful how it manifests. Hamlet: Has this fellow no feeling of his business, that he sings at grave-making? Horatio: Custom hath made it in him a property of easiness. (From Hamlet, Act V, Scene 1)

21. Resources Textbooks are too long to get through in one month, but can be read throughout residency. – Critical Care Medicine by Marini and Wheeler bases most teaching on physiologic principles to lengthen its relevancy. – The ICU Book by Marino is very popular among residents and fellows. Tarascon Internal Medicine & Critical Care Pocketbook may be a lifesaver… literally! SCCM has guidelines as well as a powerpoint series regarding basic ICU topics. a powerpoint series – $25 to take the on-line course ($10 for SCCM members). The TLC website has key articles and links to useful sites.TLC website – Link from Department of Medicine site (username: “tlcresidents”, password “Brewers1”).

22. Questions ?