Inpatient US Clinical Experience in Critical Care/Pulmonology in Miami

Information about this clinical experience:

You will be under the supervision of four physicians who specialize in internal medicine and critical care. This group of intensivists has extensive experience educating medical students and internal medicine residents.

You will rotate through a 60-bed intensive care unit in a hospital that is divided into separate units. These include the Cardiovascular Intensive Care Unit (CVICU), Neurocritical Care Unit, Medical Intensive Care Unit (MICU), Surgical Intensive Care Unit (SICU), and Cardiac Care Unit (CCU).

A wide range of patients with life-threatening conditions will be seen during this clinical experience. The emphasis will be on learning how to stabilize, evaluate, and treat these critically ill patients while working within a multidisciplinary team. To prepare for the learning opportunities in this clinical experience, rotators are encouraged to utilize the following resources prior to and during the rotation:

Medical Student’s Guide to the Intensive Care Unit

The ICU Survival Book 

The Ventilator Book

EMcrit

A typical day will be as follows:

7 AM

Upon arrival, the team will meet in the second-floor office to receive sign-out from the overnight team. A new patient census will be available to the incoming team members, and you will learn how critically ill patients are safely handed off from one care team to another.

You will be assigned to follow 1-2 patients. Over the next few hours, you will be expected to gather patient data to present to the team during rounds. Although you will collect this data from multiple sources, including the patient chart, an important source of information will be the bedside nurse. As the typical ICU nurse follows 1-2 patients, he or she can provide detailed perspectives on the patient’s status, response to treatments, and preferences of the patient and his or her family.

One of the ways you can contribute to high-quality care for your patients is by utilizing the FAST HUGS BID mnemonic on a daily basis. Your use of this checklist will ensure your critically ill patients are receiving key evidence-based care practices:

• F: Feeding (Ensure adequate nutrition)

• A: Analgesia (Assess and manage pain)

• S: Sedation (Monitor and adjust sedation levels to prevent over- or under-sedation)

• T: Thromboprophylaxis (Prevent blood clots)

• H: Head of bed elevation (Usually 30-45 degrees to reduce risk of aspiration and ventilator-associated pneumonia)

• U: Ulcer prophylaxis (Prevent stress ulcers in high-risk patients)

• G: Glycemic control (Maintain blood glucose levels in target range)

• S: Spontaneous breathing trial (Evaluate for readiness to wean off mechanical ventilation)

• B: Bowel regimen (Monitor and manage bowel function)

• I: Indwelling catheter (Assess need for catheters daily to reduce infection risk)

• D: De-escalation of antibiotics (Review antibiotic therapy to discontinue or adjust antibiotics based on clinical status and culture results)

8 to 9 AM

On Wednesday morning, you will attend morning report with the internal medicine residents. On other weekday mornings, you will be utilizing this time to get ready for multidisciplinary rounds.

9:30 AM to Noon

During this part of the day, you will take part in multidisciplinary rounds. These rounds will include the attending physician (intensivist), residents, pharmacist, nursing staff, respiratory therapist, nutrition specialist, and social worker. You will be expected to present your case(s) to the team, including differentials, assessment, and plan. The purpose of this meeting is to gather all parties involved in the patient’s care together to understand everyone’s concerns and perspectives and finalize care plans for critically ill patients. Studies have shown that interprofessional rounding in the ICU improves communication and collaboration and leads to higher-quality and safer care.

Please note that ICU patient presentations will often follow a different format (“systems-based presentation”) from presentations given in other specialties or rotations. On the first day of the rotation, rotators are encouraged to discuss the proper presentation format with the resident or attending.

1 PM to 5 PM

Afternoon rounds will take place during this time. The exact time that rounds will start depends upon attending physician preference. These rounds will provide opportunities for you to offer updates on the patients you have been assigned.

On Wednesdays, typically at 2 PM, you will attend journal club with the intensivist group and trainees.

We asked one of the intensivist attending physicians what they like to see in their rotators. Qualities that are highly valued include having a strong sense of responsibility, accountability, and attention to detail. Learners who are enthusiastic, engaged, and bring energy to the team promote positivity and boost morale. Inquisitive learners who continuously seek opportunities to learn and grow are also highly appreciated.

During your experience, you will learn the following U.S. medical practices under the preceptor’s supervision:

• Taking patient histories

• Performing physical exams under the physician’s supervision

• Presenting patients.

• Writing or entering progress notes (Meditech EMR)

• Observing procedures (e.g., thoracentesis, central line, etc.)

• Researching the literature to answer clinical questions at the point of care

• Spending time with other healthcare professionals to understand their roles and responsibilities

The patient population cared for in this hospital is diverse. Of note, 60% of patients are Spanish-speaking. If you’re not a Spanish speaker, there are multiple members of the staff that can serve as interpreters. The hospital also has interpreter services that team members can utilize.