Roles and Objectives for Fellows
WELCOME TO THE SINAI HEALTH ICU
Intro to MSH ICU
Welcome to Mount Sinai! We are located on the 5th floor of Mount Sinai Hospital. We are a 24-bed CLOSED medical and surgical ICU with several programs of excellence, including high-risk obstetrics, complex oncological surgeries, high-risk hematology/oncology patients, and Acute Care Services, which includes Emergency and Critical Care Medicine. We are also responsible for providing Critical Care Response Team Services to Princess Margaret Cancer Centre.
Our ICU has a mix of medical and surgical patients. We also have a particular interest and focus on providing critical care services to high-risk immunocompromised patients, as well as high-risk obstetrical 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 Orthopaedic Surgery.
Who Are We?
We are a collaborative, interprofessional group consisting of physicians, nurses, respiratory therapists, pharmacists, dieticians, physiotherapists, social workers and chaplains. Week to week, our ICU is led by two attending physicians to cover two clinical ICU teams and ACCESS (rapid response).
Critical Care Residents and Fellows
Your primary objective during the MSH ICU rotation is to learn. For detailed training requirements, please refer to the Interdepartmental Division of Critical Care Medicine website.
As in all ICU rotations, learning occurs primarily through clinical exposure and patient care. Other sources of education will come from both informal and formal teaching given throughout the rotation. In addition, dedicated fellows’ sessions occur weekly and will incorporate a combination of critical review of new evidence and clinical case-based discussions. As part of your rotation, we also expect fellows to fulfill the following responsibilities:
CALL AND SUPERVISION:
The Fellow Call Room is located in POD A accessible only with your badge. 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 own 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 the morning handover and must ensure appropriate sign-over to a fellow colleague prior to leaving. Also, PLEASE notify the attending when you leave – 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 call 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, and these should also be reviewed with the attendings, especially if patients are staying 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 Criticall 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 the opening of the difficult airway cart and if you are calling anesthesia +/- ENT for assistance
- Hemodynamic deterioration (e.g., high dose or multiple 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)
- Consult for a pregnant or postpartum patient
- 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 obvious solution after speaking with the ICU Team Lead and hospital Shift Manager
- Excessive clinical activity/workload that can’t be safely handled
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 and 2: ICU junior attending for Team A or Team B. You will be expected to lead and work closely with the ICU Staff. It is also a good opportunity to 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 that you want to develop more proficiency with.
- Leading/conducting family meetings
- Leading resident teaching on Thursday afternoons
- Providing teaching during daily rounds for residents
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. Encourage feedback on your performance when possible.
- ACCESS Fellow: You will be responsible for leading the ACCESS team and working with the ACCESS nurse. These responsibilities include the following:
- Rounding on patients who have been discharged from the ICU with the ACCESS RN
- Assessing new consults with the ACCESS RN
- Responding to Code Blue events during the day to support the resident acting as Code Blue Team leader
- Leading/conducting family meetings for goals of care discussions
- Providing procedural support in the ICU if the rounding teams are busy
- Fellow 4: This is the float fellow. You will be scheduled to cover the other fellows if/when they are post-call as per the daytime schedule. If you are not assigned a daytime role (Fellow 1, 2 or ACCESS), you are not expected to be present unless you are on call. Call shifts start at 4:30pm.
- Educational Opportunity: Can use this time to work with Respiratory Therapists or Registered Dieticians to get extra exposure to mechanical ventilation, or nutritional calculation etc. This is also an opportunity to work on research projects or other scholarly activities.
List of Attending Physicians and Areas of Focus
- Dr. Michael Detsky is an Intensivist and Clinician Investigator with research interests in clinical decision-making, in particular surrounding end-of-life and clinical prognostication. He is the ACCESS Lead for Mount Sinai and also has an interest in studying patient care during hospital transitions.
- Dr. Bruno Ferreyro is an Intensivist and Clinician Scientist with research focused on Respiratory Failure, ARDS, and the management of critically ill, immunocompromised patients. He has completed a Ph.D. through the Institute of Health Policy, Management, and Evaluation at UofT.
- Dr. Stephen Lapinsky is an Intensivist and Respirologist who trained in South Africa. He is a Clinician Investigator with an interest in pulmonary diseases and critical illness in pregnancy. He has collaborated on numerous guidelines and sits on several editorial boards. He is also the TGLN Lead for Mount Sinai Hospital.
- Dr. Christie Lee is an Intensivist/Respirologist and a Clinician Educator. She is the Interim Site Lead and Fellow Education Coordinator for the ICU. She is also the Chair of the Competence Committee for the Adult Critical Care Medicine Program. Her scholarly interests include the use of innovative teaching tools for education, program development, and evaluation.
- Dr. Geeta Mehta is an Intensivist/Respirologist and Clinician Scientist. She is the Research Lead for Mount Sinai ICU and is a leading expert in Sedation and Analgesia in the ICU. Current research foci also include equity, diversity and inclusivity in healthcare, post-ICU psychological and cognitive morbidity, as well as the patient and family experience.
- Dr. Laveena Munshi is an Intensivist and Clinician Scientist with research focused primarily on respiratory failure in the immunocompromised patient. She is conducting research in adjuncts to mechanical ventilation, critical illness in the oncological patient, and the development of a critical care oncology program.
- Dr. Casey Park (he/him) is an Intensivist currently completing graduate work in Epidemiology with a collaborative specialization in Global Health at the Dalla Lana School of Public Health. His current major research interest is applying social epidemiologic theoretical lenses, including syndemics and intersectionality to acute care outcomes vis-a-vis the quantification of how social structures as an exposure impact the critically ill. He is also a research associate at the Centre for Global Health and is a co-author on the Pan-Canadian Strategy for Global Health.
- Dr. Jenna Spring is the QI lead for the ICU as well as the resident education site coordinator. She has a special interest in Education and Quality Improvement with a focus on Advance Care Planning, developing early warning scores in oncological patients, and developing clinical pathways for critically ill patients with cancer.