> Home Page > Education > Community ICU Electives > William Osler Hospital

William Osler Hospital

William Osler Health Centre Critical Care Unit
Rotation Specific Goals and Objectives

 

General Objectives

The William Osler Health Centre Critical Care Unit rotation will provide exposure for residents and fellows to a mid-sized community hospital level 3 critical care unit.  The primary objective of this rotation will be to contribute to the education of residents and fellows in the area of adult critical care medicine.  Residents and fellows will have the opportunity to apply their knowledge, improve their understanding of critical illness and cultivate their skills under the supervision and direction of experienced critical care staff.  Residents and fellows will have ample exposure to the complex societal issues that are part of caring for critically ill patients and their families.  This includes the legal, moral, and ethical issues that are associated with caring for the critically ill.  Residents and fellows will gain experience at working in a team environment in which they will be expected to collaborate with professionals from various disciplines.  Residents and fellows will gain an appreciation for time management skills and its importance in being able to provide care to many critically ill patients at a time.  The WOHC Critical Care Units will educate residents and fellows within the framework of CANMEDS 2000 as proposed by the Royal College of Physicians and Surgeons of Canada; under the headings of Medical Expert/Clinical Decision – Maker, Communicator, Collaborator, Manager, Health Advocate, Scholar, and Professional.

Specific objectives for the critical care rotation at WOHC are outlined below.  In a typical one or two month rotation, exposure to clinical problems will vary somewhat depending on the case mix of patients and their medical problems.  Residents and fellows will not be exposed to all the issues raised in the learning objectives outlined below but rather a significant portion of them.   These objectives were developed based on the Royal College of Physicians and Surgeons of Canada Objectives of Training and Specialty Training Requirements in Adult Critical Care Medicine.  For fellows training in Adult Critical Care Medicine, rotating through either WOHC Critical Care Unit is expected to contribute to the resident’s achievement of all the goals and learning objectives for adult critical care medicine as set out by the Royal College of Physicians and Surgeons of Canada.
  

Specific Objectives

During their rotation through either or both of the WOHC Critical Care Units, residents and fellows will be expected to improve their knowledge and competency in several of the following areas:

Medical Expert/Clinical Decision-Maker

General Expectations:

  1. Improve their diagnostic and therapeutic skills for ethical and effective interventions at the individual, group, organization and population levels particularly as these might apply to a community hospital setting
  2. Improve their ability to access and apply relevant information to the practice of Community Medicine
  3. Improve their effective consultation services with respect to assessment and interventions at the individual, group, and population levels.
  4. Improve their understanding of epidemiology, institutional and regional morbidity and mortality, and patient high risk scoring systems (APACHE, SAPS, MODS…)

Specific Expectations

  1. Improve their knowledge base regarding generalist and specialist aspects of critical illness, code blue cardiac arrests, and critical care rapid response teams
  2. Improve their competency in the safe application of equipment, careful monitoring, judicious use of drugs, and the coordinated provision of multidisciplinary care for effective organ system support
  3. Improve their ability to recognize, resuscitate, and stabilize patients sustaining, or at risk of, cardiopulmonary arrest or other life-threatening disturbances
  4. Improve their knowledge of applied clinical physiology and homeostasis and the ability to recognize, prevent, and treat single or multiple organ failure
  5. Improve their basic understanding of physiology, pathophysiology, and pharmacology as they pertain to the critically ill patient
  6. Improve their understanding and ability to safely and in a time efficient manner transfer a patient from a community institution to a tertiary center for further investigation and treatment
  7. Improve both their basic and applied knowledge of the following dysfunctions, as outlined below:
    1. Respiratory Dysfunction
      1. Improve their ability to determine the presence of respiratory failure, provide for its emergency support, and have a plan of action to subsequently investigate and manage problems
      2. Improve their understanding of the physiology of gas exchange, lung and chest wall mechanics, airway dynamics, and the control of respiration
      3. Improve their understanding of disease states that lead to respiratory failure and the principles, theory, and application of both non-invasive and invasive ventilation
      4. Improve their understanding of managing ventilator related problems and weaning of mechanical ventilation
      5. Improve their ability to interpret chest imaging of the ICU patient
      6. Improve their understanding and ability to manage post-operative respiratory related problems; including patients post thoracotomy
    1. Cardiovascular Dysfunction
      1. Improve their ability to respond to and manage life threatening cardiac emergencies, including cardiac arrests and application of “Advanced Cardiac Life Support” techniques
      2. Improve their understanding of invasive and non-invasive hemodynamic monitoring
      3. Improve their understanding of the pathophysiology and treatment of cardiac failure
      4. Improve their ability to manage basic and complex cardiac arrhythmias, including the use of both pharmacological and electrical management
      5. Improve their understanding of shock syndromes and the pathophysiological events that lead to a shock state
      6. Improve their understanding of heart-lung interactions
      7. Improve their understanding and management of post-operative cardiac complications such as post operative myocardial infarctions, arrhythmias, and congestive heart failure
      8. Improve their understanding and management of patients with acute myocardial infarctions, cardiogenic shock, dissection, and hypertensive emergencies
    1. Neurological Dysfunction
      1. Improve their ability to recognize problems in a patient with a central nervous system crisis and/or altered level of consciousness, institute immediate life-sustaining measures, carry out an appropriate neurological examination, derive a differential diagnosis, and continue with appropriate diagnostic and supportive measures
      2. Improve their understanding of toxic, metabolic, structural, and infectious causes of altered consciousness
      3. Improve their understanding and management of increased intracranial pressure
      4. Improve their understanding of when to consult neurology, neurosurgery and when to organize transfer of a patient for neurosurgical intervention
      5. Improve their ability to investigate and manage patients suffering from seizure disorders and status epilepticus
      6. Improve their understanding of brain death and confirmatory investigations involved
      7. Improve their understanding and ability to manage environmental and drug-related psychopathology associated with critical illness (anxiety, sleep disorders, hallucinations and withdrawal)
    1. Neuromuscular Dysfunction
      1. Improve their ability to recognize a patient with an acute or chronic neuromuscular disorder, institute life-sustaining measures, and compose a program of definitive diagnosis, support, and specific therapy
      2. Improve their ability to provide specific physiological support for a patient with neuromuscular dysfunction (including support of vital organs, circulation, respiration, nutrition, bowel and bladder function, and skin care)
      3. Improve their understanding and ability to investigate and manage acute neuromuscular disease (disorders of the myoneural junction, myopathy and polyneuropathy of the critically ill, and spinal cord syndromes)
      4. Improve their understanding of the medical, administrative, and ethical considerations associated with the institution and maintenance of long-term mechanical ventilation
      5. Improve their understanding of supportive services integral to the management of patients with neuromuscular disease (physiotherapy, occupational therapy, orthotics, social services)
    1. Renal Dysfunction
      1. Improve their ability to recognize a patient with oliguria and/or evidence of advancing or established renal failure, institute measures to preserve remaining renal function, and provide for precise diagnosis, adequate supportive measures, and appropriate therapy
      2. Improve their understanding of the pathphysiology and management of acute renal failure
      3. Improve their understanding of the renal replacement therapy in the intensive care unit
    1. Gastrointestinal Dysfunction
      1. Improve their ability to evaluate a patient who presents with gastrointestinal crisis, institute immediate life-sustaining support, and develop a diagnostic and therapeutic plan
      2. Improve their knowledge of the etiology, diagnosis and management of an acute abdomen, bowel obstruction, ischemia, perforation, dysmotility, upper and lower GI bleeding, pancreatitis, biliary tree disease and post operative abdominal surgery complications
    1. Hepatic Dysfunction
      1. Improve their ability to recognize a patient with jaundice and/or hepatic failure, provide for immediate life-sustaining support, and develop a diagnostic and therapeutic plan
      2. Improve their knowledge of the pathophysiology and management of acute and chronic liver disease
    1. Hematological/Oncological Disorders
      1. Improve their ability to recognize, investigate, monitor, and manage (including the ability to provide life-sustaining support) a patient with  a malignancy, a thrombotic or thrombolytic disorder, bleeding, neutropenia, anemia, thrombocytopenia, hemolysis, vaso-occlusive diseases and oncologic emergencies
      2. Improve their knowledge of the coagulation cascade and disorders affecting it
      3. Improve their knowledge of the risks, benefits, and indications of blood component therapy and management of transfusion related complications
      4. Improve their knowledge of the indications, contraindications and complications of DVT prophylaxis, anticoagulant and thrombolytic therapies
    1. Metabolic-Endocrine Disorders
      1. Improve their ability to recognize the nature and severity of the problem of a patient with metabolic, endocrine, and/or fluid/electrolyte abnormalities, establish a differential diagnosis, and embark on a course of definitive diagnosis, treatment, and continued monitoring and support
      2. Improve their ability to diagnose and manage fluid and electrolyte disturbances
      3. Improve their understanding of the pathophysiology, diagnosis, and treatment of acid-base disorders, endocrine disorders and emergencies, and abnormalities of body temperature regulation
      4. Improve their knowledge of the use of intensive insulin therapy in intensive care unit patients
      5. Improve their knowledge of relative adrenal insufficiency and steroid replacement in intensive care unit patients
    1. Septic Illness
      1. Improve their ability to recognize a patient with catastrophic septic illness, institute immediate life-sustaining measures, establish a differential diagnosis (site of origin, etiological pathogens), and embark upon a course of definitive diagnosis, continued life support, and appropriate antimicrobial and/or surgical therapy
      2. Improve their knowledge of diagnosing and managing infectious disease in immunocompetent and immunocompromised patients
      3. Improve their knowledge of preventative infection control techniques, including antibiotic prophylaxis of contacts when appropriate
      4. Improve their knowledge of the pharmacology, indications, complications, interactions, monitoring and efficacy of antimicrobial agents, activated protein C, and other medical treatments for sepsis
      5. Improve their understanding of and the ability to diagnose and manage SIRS, sepsis, severe sepsis, septic shock, MODS
    1. Intoxication
      1. Improve their understanding of and their ability to formulate a differential diagnosis for a patient potentially suffering from a toxic syndrome and then undertake a sequential plan to support organ function, prevent further toxin absorption, alter toxin distribution, and if possible, enhance toxin elimination by natural and mechanical means
      2. Improve their understanding of supportive therapy pertinent to individual intoxicants, the pharmacology of common intoxicants, and the use of specific antidotes
      3. Improve their understanding of strategies to reduce toxin absorption and enhance elimination (hemodialysis, hemoperfusion)
    1. Nutritional Support
      1. Improve their ability to evaluate the nutritional status of the critically ill patient, identify current deficiencies, ongoing losses, and extra needs induced by the illness
      2. Improve their ability to devise a management strategy for the provision of either enteral and/or parenteral nutrition to sustain the patient throughout the period of critical illness
      3. Improve their understanding of fluid compartments and fluid/caloric requirements in the critically ill patient
      4. Improve their understanding of the techniques and laboratory tests used to evaluate nutritional status and basal energy expenditure
      5. Improve their understanding of the indications, limitations, methods and complications of enteral and parenteral nutritional techniques
    1. Pharmacotherapy
      1. Improve their knowledge of the indications, risks, and side effects of relevant pharmacotherapy in critically ill patients
      2. Improve their understanding of the pharmacologic and therapeutic applications of drugs, their side effects, and potential drug interactions in critically ill patients
      3. Improve their understanding of the indications for, and use of sedation, analgesia, and neuromuscular blockade in critically ill patients
    1. Transportation
      1. Improve their understanding of the problems peculiar to the transportation of the critically ill patient including the importance of communication, triage, preparation prior to and during transport, the unique monitoring and management problems associated with transport, the role of paramedical personnel, and the determination of need for physician accompaniment
    1. Ethical and End of Life Issues
      1. Improve their understanding of complex ethical issues in the intensive care unit including ethical issues surrounding the withdrawal of life support treatment
      2. Improve their knowledge of withholding and withdrawing life sustaining therapies, instituting pain and symptom management, instituting psychological, social and spiritual support for both the patients and their families
      3. Improve their communication abilities with patients and their families
    1. Critical Illness in Pregnancy
      1. Improve their ability to investigate, diagnose, and manage (including the provision of life sustaining therapies) a peri-partum or pregnant woman suffering from critical illness during or shortly after pregnancy
      2. Improve their knowledge of maternal cardiovascular, respiratory, and renal physiology during pregnancy
      3. Improve their ability to diagnose and manage specific pregnancy related diseases including pre-eclampsia/eclampsia, pulmonary disorders, cardiac disorders, acute renal failure and hepatic failure
    1. Critical Care Rapid Response Teams
      1. Improve their understanding of the role and function of critical care rapid response teams
      2. Participate in the daily functioning of a critical care rapid response team in a large community hospital
    1. Improve and fine tune their ability to perform the following core skills
      1. Airway
        1. Assessment and maintenance of a patient’s airway
        2. Orotracheal intubation
        3. Indication for tracheostomy
        4. Replacement of a preexisting tracheostomy tube
        5. Cricthyrodotomy and indication for other urgent surgical airways
        6. Airway management during an unexpected difficult intubation
        7. Anaesthesia and airway management during initial tracheostomy tube insertion in the intensive care unit
        8. Fiberoptic intubation
        9. Laryngeal mask airway
      2. Breathing
        1. Ventilation by bag and mask
        2. Application of conventional positive pressure mechanical ventilation
        3. Application of non-invasive ventilation
        4. Advanced ventilation strategies
        5. Measurement and interpretation of pulmonary mechancics during mechanical ventilation
        6. Application of an end-tidal CO2 detector post-intubation
        7. Application of pulse oximetry
        8. Ventilation weaning techniques
        9. Fiberoptic bronchoscopy in the intubated patient
        10. Thoracentesis
        11. Thoracostomy tube insertion
      3. Circulation
        1. Arterial lines
        2. Central venous lines
        3. Utilization, zeroing, and calibration of transducers
        4. Application and maintenance of a pulmonary artery catheter
        5. Cardiac output measurements and other derived calculations from pulmonary artery catheters
        6. ECG interpretation
        7. Defibrillation
        8. Elective cardioversion
        9. Cardiac overdrive pacing
        10. Temporary transvenous pacemaker
        11. Temporary transcutaneous pacemaker
        12. Pericardiocentesis
        13. Prevention and management of air embolism
      4. Central Nervous System
        1. Declaration of brain death
        2. Lumbar puncture
        3. Therapy aimed at maintenance of cerebral perfusion pressure
        4. Monitoring the degree of neuromuscular blockade with peripheral nerve stimulation
      5. Renal
        1. Insertion of temporary hemodialysis catheter
        2. Indication for continuous renal replacement therapy
      6. Gastrointestinal
        1. Intra-abdominal pressure monitoring
        2. Paracentesis
        3. Gastro-esophageal balloon tamponade
      7. Nutrition
        1. Determination of a nutritional plan
      8. Transport
        1. Organization and supervision of inter- and intra-city transfers
      9. Other
        1. Use of special beds
        2. Application of techniques to treat or induce hypo/hyperthermia
Additional CANMEDS 2000 GOALS

Residents and fellows rotating through the WOHC Critical Care Unit will have the opportunity to improve their skills with respect to the following:

Communicator
  1. Establishing relationships with patients and families
  2. Listening effectively
  3. Obtaining and synthesizing relevant history from patients/families/communities
  4. Discussing appropriate information with patients/families and the health care team
Collaborator
  1. Consulting effectively with other physicians and health care professionals
  2. Contributing effectively to interdisciplinary team activities

 

Manager
  1. Allocating finite health care resources wisely
  2. Working effectively and efficiently in a health care organization
  3. Utilizing information technology to optimize patient care, life-long learning, and other activities
  4. Utilizing personal resources effectively to balance patient care, learning needs, and outside activities
Health Advocate
  1. Identifying the important determinants of health affecting patients
  2. Contributing effectively to the improved health of patients and communities
  3. Understanding the diverse determinants of health, disease, and illness including relating occupational and environmental exposures, socio-economic factors and life style factors to critical illness
  4. Understanding the health care system and the structure and function of critical care units
  5. Understanding the medico-legal considerations for the critically ill

 

Scholar
  1. Developing, implementing, and monitoring a personal continuing education strategy
  2. Practicing “evidence based medicine”
  3. Competently appraising
    1. Levels of evidence
    2. Interventions
    3. Diagnostic tests
    4. Prognosis
    5. Integrative literature (meta-analysis, practice guidelines, decision and economic analysis)
  4. Efficiently accessing information from the medical literature using current information retrieval tools
  5. Practicing the principles of adult learning
Professional
  1. Delivering the highest quality care with integrity, honesty, and compassion
  2. Developing personal and interpersonal professional behaviours
  3. Practicing medicine ethically consistent with the obligations of a physician
  4. Understanding moral and ethical issues as they impact on patients, their families and critical care providers
  5. Understanding the role and responsibilities of the critical care physician at the local, community, regional, and national levels
  6. Recognizing and dealing with ethical issues in the ICU including truth-telling, consent, conflict of interest, resource allocation, and end-of-life care

 

 

logo Department of Medicine