Rotation Objectives for Fellows
Overall, the educational objectives for the ICU rotation at Sinai Health are based on the Royal College of Canada core competencies in Adult Critical Care Medicine.
Our hospital has several programs of excellence, including high-risk obstetrics, complex oncological surgery, and high-risk hematology/oncology. We are also responsible for providing Critical Care Response Team Services to Princess Margaret Hospital.
Our ICU has a mix of medical and surgical patients. We also have a particular interest in providing critical care services to high-risk, obstetrical and immunocompromised patients. In support of the surgical department, we also provide post-operative care to HIPEC patients in conjunction with General Surgery and complex sarcoma patients in conjunction with Orthopedic Surgery.
CALL AND SUPERVISION:
As fellows, you will be doing 24 hours of in-house call coverage for the duration of your ICU rotation. As part of your development as a leader and consultant, you will need to develop your level of comfort in allowing residents to have some clinical independence WITHIN safe limits during the call nights. All fellows are expected to be present for morning handover and must ensure appropriate sign-over to a colleague before leaving. Also, PLEASE notify the attending when you go – this is important to maintain safety in patient care. The role of the attending physicians is to support learners and ensure excellent patient care.
We expect to be called, and please never hesitate to contact us.
- If you are in your first year of a CCM residency (or the first 6 months of your CCM clinical fellowship), we expect to get called about all new admissions and consults that you review with the residents. These calls can be batched, especially if you have a few at a time. You will also respond to ACCESS consults overnight, but these should also be reviewed with the attending, especially if the patient is going to stay on the floor.
- As a CCM resident in year 2 (or the latter half of a CCM clinical fellowship), we allow some graded responsibility and independence; you should call when you need to, but not be obliged to if the situation is under control (i.e., routine post-op patients). In addition, to develop more independent consultation skills, you can take consults from critical during the day, review cases with the ACCESS nurse overnight, and have more autonomy in the unit during ward rounds.
For admitted inpatients, you should call the attending for the following:
- Cardiopulmonary arrest (except in patients with a No CPR order)
- Anticipated or actual difficult intubation, including opening the difficult airway cart or calling anesthesia +/- ENT for assistance
- Hemodynamic deterioration (e.g. high dose vasoactive agents needed for support), especially if they are not responding to your initial management strategies.
- Gas exchange or lung compliance problem leading to sustained high FiO2 (e.g. ≥80%) or adjunctive respiratory therapy instituted or planned (e.g. inhaled NO, proning)
- Procedural complication (e.g. pneumothorax after CVL or arterial placement of CVL)
- Complication requiring consultation or intervention from another service (e.g. laparotomy for suspected ischemic bowel, coronary angiogram for MI)
- Major conflict with family/substitute decision-maker
- Major conflict with another clinical team
- Any concerns or uncertainty about management, procedures, or processes of care
- Problem with bed flow and no apparent solution after asking patient flow/shift manager to check
- Excessive clinical activity/workload that can’t be handled safely by fellows and residents
Please refer to the PARO guidelines for rules and regulations regarding on-call coverage.
You are expected to lead rounds and act as the junior attending physician as much as possible. The call schedule will list your fellow assignments for the week.
- Fellow 1: ICU junior attending of the week; you will split the unit to lead rounds and work closely with the ICU Staff, and as much as possible, work with the interprofessional team to lead the unit. In addition, you will be responsible for:
- Achieving competency and excellence in ICU procedures. You are here to learn and therefore have priority on airway and other procedures.
- Leading/conducting family meetings
- Teaching during daily rounds
Tip: Check-in with your staff person on Monday and decide how you want to structure the week. You will find that ICU staff vary in their level of supervision. Mondays are often different because the staff are also learning about the patients. Encourage feedback on your performance when possible.
- Fellow 2: is the ICU B/ACCESS fellow and will work closely with the ACCESS RN and ICU B MD for the week. If there is no Fellow 3 for the week, you may be asked to take over as Fellow 1 for the day if they are post-call. You will also be responsible for:
- Leading rounds on the 16th floor ICU (if there are patients there)
- Assessing new consults with the ACCESS RN and rounding on patients as part of the ACCESS team
- Fellow 3: is the float fellow. You are expected to:
- Cover fellow 1 or 2 if/when they are post-call
- Being present during sign-over and in case extra assistance is needed in the ICU i.e., admissions during rounds
- Lead teaching sessions on Mondays at 3 pm for resident teaching
- We also encourage you to join/participate in rounds for personal learning
- Fellow 4: Education Fellow
- Will be responsible for the Friday Fellows Journal Club
- Educational Opportunity – spending time with the Respiratory Therapists or Registered Dieticians to get extra exposure to mechanical ventilation, nutritional calculation etc, or working on scholarly work
- Time to work on Research Projects and Scholarly Activity