ME538M.23

Medical Intensive Care Unit Experience - BWH

Credits: 4.00 CREDITS (Clinical Elective)
Directors: Massaro, Anthony Francis
Prerequisites: HMS Principal Clinical Experience (Core Clinical Clerkships) or equivalent
Offered: Full time every month, except July.
Open to Exclerks: No (HMS only)
Description:
In this clerkship students will be introduced to the evaluation and management of patients in a tertiary care center Medical Intensive Care Unit. The student will be part of a team comprised of 3 interns, 3 residents, a critical care fellow and an attending Pulmonary and Critical Care physician. Students will be responsible for evaluation of patients on admission and follow these critically ill patients throughout their ICU stay. With assistance from the intern and resident, the student will formulate and present a daily plan of care. The student will take call every fourth night with an intern and resident.

During the rotation, the student will gain an understanding of the pathophysiology and management of patients with a variety of critical illneses including respiratory failure, hypotension, sepsis, gastrointestinal bleeding and renal failure. As an integral member of the team, the student will also interact with varied consultative services and participate in regular family meetings. The student will gain exposure to a variety of procedures performed in the intensive care unit including placement of central venous access, arterial access, thoracentesis, paracentesis and bronchoscopy. Activities will also include participation in daily morning didactic teaching session as well as regularly scheduled MICU conferences (Ethics Rounds, Journal Club, Morbidity and Mortality Conference and a shared MICU/SICU conference). During the last week of the rotation, the student will be expected to lead a teaching session on a critical care topic of their choice.
Learning Goals:
Respiratory failure – Student will develop an understanding of the pathophysiology of respiratory failure. Instruction will be provided on the use on both invasive and non-invasive modes of mechanical ventilation. Ventilator management teaching will include lung protective ventilator strategies.
Hypotension - Students will be instructed in the evaluation and treatment of patients with hypotension. This will include the differential diagnosis of hypotension, an understanding of methods of hemodynamic monitoring and instruction on the use of vasopressors. Students will gain familiarity in the identification of patients with sepsis and the evaluation for a source of sepsis. They will understand the role of early goal directed therapy, vasopressors and supplemental steroids in the septic patient.
Medical Ethics - Students will gain an understanding of the ethical principles involved in management of critically ill patients. This includes instruction regarding end-of-life care for critically ill patients. This will be facilitated by a weekly case based ethics conference.
Quality control in the ICU - Student will gain an understanding of initiatives to minimize development of catheter related blood stream infections, ventilator acquired pneumonias and other complications of critical illness.
Incorporation of Basic Science Content and Evidence-Based Medicine:
An understanding of basic pathophysiology and evidence based medicine will be emphasized on daily rounds and in the daily morning teaching conference. Teaching focused on the patient-ventilator interaction is an ideal format to reinforce principles of pulmonary physiology and pathophysiology. Similarly, discussions related to shock require a return to cardiac physiology and pathophysiology.

Students will learn about evidence-based approaches to the management many critical care topics incluidng ARDS (low-tidal volume ventilation, ideal volume status, use of steroids), sepsis (early goal-directed therapy) and transfusion practices in the ICU.

This teaching will be a part of daily rounds as well as the daily didactic teaching session.
Evaluation:
Students will be evaluated by all attendings with whom they work during the clerkship with input from the PCCM fellow on service as well. History taking, physical diagnosis, presentations as well as knowledge base will be assessed. In addition, the student's ability to communicate with patients and consulting teams will be incorporated into the evaluation. Finally, the student's small group presentation will be assessed and factor into the overall grade.
Grade Criteria:
High Honors:
Ability of the student to consistently perform on a level exceeding expectations for someone at their degree of training. This includes history taking which misses very few details, comprehensive physical diagnosis with particular skill in obtaining pulmonary findings, concise and complete oral presentations and notes as well as an exemplary knowledge base. Students receiving high honors will demonstrate the ability to communicate clearly with families and consulting teams. Additionally, this grade requires a student presentation which is outstanding in the estimation of the attending.

Honors:
Ability of the student to consistently perform at or above the level of someone at their degree of training. This includes an outstanding performance on at least three aspects of their evaluation include history taking, physicial diagnosis, fund of knowledge, communication skills, oral presentations and note writing.
Satisfactory:
Ability of the student to perform at or near the expected level of someone at their degree of training with respect to history taking, physicial diagnosis, fund of knowledge, communication skills, oral presentations and note writing.
Unsatisfactory:
Inability to perform at the expected level of someone at their degree of training with respect to more than one of the following: history taking, physicial diagnosis, fund of knowledge, oral presentations and note writing.
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