Medeck 620: Sub-internship in Critical Care Medicine

Rotations

overview | goals & objectives | eligibility | structure | responsibilities
teaching methods | schedule | reading materials | evaluation

Harborview Medical Center

Clerkship Director & Faculty Contact:

Andrew M. Luks, MD
Harborview Medical Center
Mail Stop: 359762
Email: aluks@u.washington.edu
Phone: 206-744-4161

Administrative Contact:
Leila S. Armas
Email: lsarmas@u.washington.edu
Phone: 206-744-3356

Clerkship Overview

Fourth year medical students will function at the sub-intern level on the Medical Intensive Care Unit (MICU) service at Harborview Medical Center. During the rotation, they will have direct patient care responsibilities through which they will learn about various forms of critical illness and how to apply different therapeutic and diagnostic modalities commonly used in critical care medicine.

Learning Goals and Objectives

The primary goals of this rotation are as follows:

  • To learn how to evaluate and manage patients with different forms of critical illness including respiratory failure, hypotension, sepsis, organ failure and gastrointestinal hemorrhage
  • To learn how to initiate and manage invasive and non-invasive modes of mechanical ventilation
  • To learn how to interpret and apply the results of arterial blood gas analysis
  • To learn how to protect patients from complications associated with stays in the intensive care unit
  • To learn about the application of palliative care medicine principles in the intensive care unit setting.
  • To learn to work as part of a multidisciplinary care team

At the end of this rotation, students should be able to:

  • Evaluate and manage patients with various forms of respiratory failure including COPD and asthma exacerbations, pneumonia, acute respiratory distress syndrome and pulmonary edema
  • Evaluate and manage patients with sepsis and severe life-threatening infections
  • Evaluate and manage patients with severe organ failure including renal, hepatic and coagulation failure
  • Evaluate and manage patients with gastrointestinal hemorrhage
  • Evaluate and manage patients with severe hypotension
  • Evaluate and manage patients with severe metabolic and endocrinologic disturbances
  • Initiate appropriate empiric antibiotic coverage for patients with severe infections
  • Initiate and titrate vaso-active medications
  • Initiate, manage and discontinue both invasive and non-invasive modes of mechanical ventilation.
  • Interpret arterial blood gases and apply this information in the care of patients
  • Initiate appropriate measures to prevent complications associated with ICU care
  • Apply the principles of palliative care medicine to patients in the intensive care unit

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Eligibility

The sub-internship will be open to 4th year medical students by departmental permission.

The rotation will be offered from September until May of each year.

Structure of the Rotation

The MICU service at Harborview Medical Center consists of an attending physician, pulmonary and critical care fellow, 4 senior residents and 4 interns. The sub-intern will be paired up with one of the senior residents and will take call with that resident and their corresponding intern on an every 4th night basis.

The sub-intern will work an average of less than 80 hours per week during the rotation and will have a total of 4 days off per month. The specific days off will be determined at the start of the rotation. On workdays, the sub-intern will be expected to arrive at a time that will allow them to adequately pre-round on all of their patients before the morning didactic sessions. The workday will conclude when they have completed their work on all of their patients and have signed out with the pulmonary fellow and/or attending physician. Sub-interns may be asked to assist with the care of other patients as part of the team’s work covering for residents and interns who have the day off or as part of an effort to get the post-call team out of the hospital but all such requests are at the discretion of the attending or fellow on the service. On call nights, the sub-intern will adhere to the same work-hour requirements as the resident and intern and will not work more than 30 consecutive hours at a time.

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Sub-intern Responsibilities

Working under the supervision of the pulmonary and critical care fellow and their senior resident, the sub-intern will be responsible for all aspects of care for their patients. They will be expected to write all admission and daily progress on their patients and to communicate with consultants and other providers that are part of the multidisciplinary MICU team.

At the start of the rotation, the sub-intern will admit one patient per night but as the rotation progresses this total may be increased to 2 patients per call night at the discretion of the supervising resident, fellow or attending physician based on the sub-intern’s demonstrated skills and current patient load. Sub-interns may be responsible for up to 4 patients at any one time.

During the course of their work on the service, sub-interns may also gain experience in certain procedures including central venous catheter or arterial line placement. However, priority for all therapeutic and diagnostic procedures goes to the interns and residents on the service and the sub-intern may have to defer to these individuals in certain situations, even when such procedures are being performed on their patients. In the era of work-hour requirements and caps on admissions, it has become increasingly difficult to ensure that the resident staff get adequate procedural experience. It is for this reason that priority for all procedures goes to the resident staff. If they have done an adequate number of the procedure in question or are too busy with other work to complete the procedure, then the sub-intern will have an opportunity to do the procedures.

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Principal Teaching Methods

Several different teaching modalities are employed on this service:

  • Case discussion and review: The sub-intern will review all admissions with their senior resident and will review the care of all of their patients with the fellow and attending physician on a daily basis.
  • Work rounds: Bedside teaching occurs daily on work rounds with the volume of teaching varying based on the current workload on the service.
  • Didactics: Attending rounds take place 3 days per week (Monday, Tuesday, Thursday) from 8:00 to 8:30AM. Palliative care / Death rounds generally occur on Fridays at 8:00AM. If rounds have finished by 10:00 AM, sub-interns may also attend Morning Report on Mondays, Tuesdays, Wednesdays and Fridays from 10:00 to 11:00AM. Finally, the sub-intern is expected to attend noon conferences that occur on a daily basis in the R&T building. The schedule for these and other sessions is provided below.

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Weekly Schedule

The weekly schedule for the rotation is as follows:

Monday Tuesday Wednesday Thursday Friday Sat/Sun
7:30 AM X-ray rounds* X-ray rounds X-ray rounds X-ray rounds X-ray rounds
8:00 AM Attending Rounds Attending Rounds Work Rounds Attending Rounds Palliative Care / Death Rounds X-ray rounds
8:30 AM Work rounds Work rounds Work rounds Work rounds Work rounds Work Rounds
11:00AM Multi-disciplinary Critical Care Conference†
12:30 PM Dept of Medicine Teaching Conference Chief of Medicine Rounds or M&M Conference Dept of Medicine Teaching Conference SACGR§ (12:15 PM)
Intern Report		 Cardiology Conference Mid-late afternoon: Sign-out rounds
1:30 PM RCCC¥
5:00 PM Sign-out rounds Sign-out rounds Sign-out rounds Sign-out rounds Sign-out rounds

* X-ray rounds take place in the MICU workroom
† Multidisciplinary Critical Care Conference occurs with the SICU and NCCS teams at noon
§ SACGR = Seattle Area Chest Grand Rounds (R&T Building)
¥ RCCC = Respiratory Critical Care Conference (R&T Building)

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Reading Materials

There is no required reading for the clerkship. Sub-interns are, however, expected to read materials relevant to the care of their patients and other patients on the service as time permits during their rotation. Available sources of reading materials include:

  • The MICU team has a small library maintained by the Section of Pulmonary and Critical Care Medicine located in the MICU team room. There is also a hospital library available 24 hours a day. The Division syllabus containing selected articles relevant to the rotation is maintained there.
  • Electronic Syllabi: Two electronic syllabi are available for use by the sub-intern. Each syllabus contains a variety of primary research and review articles pertinent to pulmonary and critical care medicine
  • Students may also access the website that has been created for Medicine 683, the 4th year student clerkship in Pulmonary Medicine which contains a large volume of teaching materials relevant to critical care medicine. The URL for this website is: https://courses.washington.edu/med683/index.html
  • Suggested Textbooks:
    • Principles of Critical Care, 3rd Edition: Hall JB, Schmidt GA and Wood LDH eds. New York: McGraw-Hill. 2005.
      This is a large comprehensive textbook that is good for looking up specific topics. It is too expensive to consider purchasing for this rotation but is available in the MICU team room.
    • The Intensive Care Unit Manual. Lanken PN, Hanson W, Manaker eds. Philadelphia: W.B. Saunders. 2001.
      This is a much smaller textbook and something that is worth considering for purchase. It is an excellent source of condensed information about a wide range of critical care medicine topics. A copy is also available in the MICU team room.

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Performance Evaluation

At the end of the rotation, the student’s performance will be evaluated by the attending physician, pulmonary and critical care fellow and senior resident using the current Evaluation of Student Performance in the Clinical Curriculum form. This evaluation is completed on-line but the sub-intern will also receive feedback in person from each of their evaluators.

Students will be graded on an Honors / High Pass / Pass / Fail Basis. There are no examinations or required assignments for this rotation. In order to pass the rotation, students must be present for all assigned workdays and must demonstrate the ability to adequately execute patient care responsibilities.

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