SICU & Critical Care
The SICU at Hillcrest:
Welcome to the Surgical Intensive Care Unit!
Our goal is to provide you with the education necessary to take care of the most difficult to manage surgical patients. We can give you a wide breadth of experience dealing with a variety surgical patients.
The Surgical Intensive Care Unit (SICU) is a 20-bed, fast-paced, high-acuity, multi-specialty critical care unit. The surgical specialties supported in the SICU include trauma, neurosurgery, general surgery, cardiothoracic surgery, transplant, orthopedics, spine, ear nose and throat, plastics, vascular surgery, urology and high risk obstetrics. The SICU is adjacent to the three-bed Level 1 Trauma Center. Over 1,800 patients are admitted to the SICU annually. During times of peak patient admission, the SICU has the ability to overflow to an additional six beds.
The Medical Director of the SICU is Dr. Jay Doucet and the SICU Nurse Manager is Juana Burkhart, RN and CCRN. Their role is to coordinate the multi-specialty medical care that is commonly delivered by specialty teams to critically ill patients; and ultimately bring all the services and professionals together with the common mission of providing excellent care to the residents of San Diego County. The SICU Critical Care Service attendings are general surgeons and anesthesiologists who have additional certification in Critical Care. They are assisted by two fellows who are board-eligible or board-certified general surgeons training for additional certification in Critical Care Surgery.
The educational program for all levels includes daily teaching rounds, seminars, psychomotor skills sessions and human patient simulator sessions.
The Surgical ICU rotation is organized by the Division of Trauma, Burn & Surgical Critical Care faculty, in coordination with the Anesthesiology faculty and residents. PGY1 or 2 residents rotate from various programs, including general surgery, anesthesiology, reproductive medicine, orthopedic surgery, family medicine plus other designated and non-designated residents.
The SICU is an “semi-open unit”, meaning that surgeons from services with critical care privileges (most general, cardiac and neurosurgeons) usually retain primary control of their own patients care while in the SICU. For example, a vascular patient of Dr. Angle’s remains on the Red Service, and the SICU residents act as on-site consultants to this patient. Some services do not have critical care privileges - such as Urology, Orthopedics, ENT, Plastics. OB/GYN, Interventional Radiology, Ophthalmology and others. In these cases the SICU Critical Care Service will act as the primary service. In this situation, the SICU attending is the physician in charge, and the other primary team will confine their management input to their specialty issues. In an emergency, if the primary service is unavailable, the SICU Critical Care Service may make orders to save the life and health of any patient in the SICU.
There are robust attending rounds held daily, M-F, for all SICU residents. SICU residents are expected to be aware of the daily care issues for all patients, all services, as appropriate to their level of training and continuity of care. Expect to contribute to the patient care discussion on all patients- not just your own!
Scheduled Daily Activities
0630-0800: Pre-round with input from primary teams
0800-0830: Assemble rounds materials with SICU Fellow
0830-1000: Attending rounds
1030-1130: Daily SICU Seminar with resident presentation, except weekends
1230-1430: Simulator / Skills session – Thursdays and/or Fridays
1500-1700: Trauma conference, Tuesdays only
Faculty are usually on the SICU Critical Care Service for one week periods. Fellows take the service for one month periods. There is always a SICU/Trauma faculty member or fellow in the hospital. If there are any questions, concerns, criticisms, or you just want to talk, please contact any or all of the following:
Specific Goals by PGY
PGY I/II - Surgical Intensive Care Unit Service
A. Medical Knowledge
- The resident should learn in depth the fundamentals of basic science as they apply to patients in the intensive care unit. Examples include anatomy, physiology and patholophysiology of the cardiovascular, respiratory, genitourinary, gastrointestinal, musculoskeletal, hematologic, endocrine systems, respiratory failure, coronary ischemia, shock, malnutrition, stress ulceration, nonocclusive intestinal ischemia, antibiotic-associated colitis, antibiotic resistance, jaundice, and renal insufficiency.
- The resident should understand the rationale for admission and discharge criteria in the ICU.
- The resident should understand factors associated with assessment of preoperative surgical risk. Examples include evaluation of the high risk cardiac patient undergoing non-cardiac surgery.
- The resident should understand fluid compositions and the effect of the losses of such fluids as gastric, pancreatic and biliary fistulas at various levels.
- The resident should understand the indications for, and complications of blood component therapy.
- The resident should be able to discuss the pathophysiology of respiratory failure.
- The resident should be able to demonstrate an understanding of acid-base disorders, including diagnosis, etiology, and instituting appropriate treatment.
- The resident should be able to discuss the pathophysiology, indications, and complications associated with various modes of mechanical ventilation. Examples include ventilator management of ALI, ARDS and thoracic trauma, as well as weaning from ventilatory support.
- The resident should understand the role of hormones and cytokines in the graded metabolic response to injury, surgery and infection.
- The resident should understand the indications, routes and complications of administration of parenteral and enteral forms of nutrition.
- The resident should understand the factors associated with altered mental status. Examples include traumatic, septic, metabolic and pharmacologic causes.
- The resident should understand the risk factors associated with stress gastritis.
- The resident should understand the causes and treatment regimens for gastrointestinal bleeding. Examples include bleeding from upper and lower GI sources.
- The resident should understand the factors associated with bleeding disorders. Examples include DIC, ITP, hemophilia, coagulopathy associated with shock and hypothermia.
- The resident should understand the pathophysiology of hemodynamic instability. Examples include types of shock, cardiac arrest.
- The resident should know and apply treatments for arrhythmias, congestive heart failure, acute ischemia and pulmonary edema.
- The resident should understand adjuncts to the analysis of respiratory mechanics and gas exchange. Examples include work of breathing, rapid shallow breathing index, CO2 analysis and dead space measurements.
- The resident should understand fluid and electrolyte as well as acid/base abnormalities associated with complex surgical procedures and complications. Examples include massive fluid shifts associated with trauma, shock and resuscitation, high output fistulas and renal failure.
- The resident should understand the pathophysiology associated with endocrine emergencies in the ICU. Examples include thyroid storm, hyper, hypoparathyroid states and adrenal insufficiency.
- The resident should understand the risk factors and common pathogens that are associated with nosocomial infections.
- The resident should be able to discuss the mechanism of action as well as the spectrum of antimicrobial activity of the different antibiotic classes. Examples include carbapenams, extended spectrum penicillins and fluoroquinolones.
- The resident should understand the risk factors that result in multiply resistant organisms. Examples include antibiotic dosing, antibiotic synergy and transmission patterns.
- The resident should be able to discuss the factors that result in an immunocompromised state. Examples include malignancy, major trauma and steroids.
- The resident should understand the pathophysiology of traumatic brain injury and neural disease. Examples include knowledge of intracranial pressure monitoring and maneuvers to normalize ICP.
- The resident should be able to discuss the pathophysiology, presentation, and causes of hepatic failure.
- The resident should be able to discuss the pathophysiology, presentation, and causes of renal failure and indications for intermittent dialysis or continuous hemofiltration. Examples include pre-renal failure, acute tubular necrosis, hepatorenal syndrome.
- The resident should be able to discuss end of life ethical issues. Examples include organ donation and withdrawal of support.
B. Patient Care
The resident should be able to:
- Create accurate and complete progress and procedure notes, that are always signed, include ID number, date and time.
- Evaluate critically ill patients and make supervised decisions regarding patient care.
- Utilize a daily rounding checklist (FASTHUGGS) to ensure all prophylactic measures against infectious and other complications are in compliance.
- Read plain radiography and CT imaging and show proficiency in reading chest and abdominal X-rays.
- Under appropriate supervision, the resident should be able to
- Insert central venous catheters using ultrasound guidance in full compliance with central line precautions bundles
- Insert, interpret and troubleshoot pulmonary artery catheters and arterial lines
- Insert chest tubes and manage chest drainage sets
- Perform bedside ultrasound
- Resuscitate patients from shock and cardiac arrest.
- Recognize and treat ischemia and arrhythmias on ECG.
- Utilize correct class of anti-arrhythmic, vasodilators and diuretics as they pertain to cardiac disease.
- Correctly determine the protein, caloric, electrolyte, fat and vitamin needs of surgical patients, taking into account their underlying disease process.
- Correctly diagnose and treat gastrointestinal bleeding associated with ulcers, portal hypertension and lower GI sources.
- Diagnose cause and appropriately alter treatment regimens to compensate for hepatic failure.
- Perform the following aspects of ventilatory management:
- Set up initial and advanced ventilator settings.
- Wean patients from ventilatory support using the STEER protocol.
- Treat common complications of mechanical ventilation, including pneumothorax and tube thoracostomy.
- Provide cardiovascular support including, but not limited to, invasive monitoring, use of inotropes and vasopressors, management of dysrhythmias.
- Utilize appropriate blood product transfusion indications and alternatives.
- Correctly utilize prophylaxis for stress gastritis in high risk ICU patients.
- Initiate appropriate nutritional support through the optimal route and manage complications of nutritional support.
- Assist in managing patients with intracranial hypertension and cerebrovascular disease.
- Use antibiogram, clinical and pharmacy resources to prescribe appropriate antibiotics.
- Apply concepts of patient isolation and prevent spread of nosocomial infection.
- Initiate appropriate DVT prophylaxis and manage thromboembolism.
- Provide culturally sensitive care and gain skill in providing end-of-life care.
- Understand and provide Patient-Centered and Family-Centered Care.
- Consult the Palliative Care (Howell) service when indicated.
C. Interpersonal and Communications Skills
- Gain knowledge in the education of patients and families in post operative and rehabilitative strategies,
- Be expected to interact and communicate with other Critical Care team members in an effective, professional manner to facilitate highly effective care
- Develop skills in providing adequate counseling and informed consent to the critically ill patient and their families.
D. Practice-Based Learning and Improvement
- The resident should use books, journal articles, internet access, the trauma.ucsd.edu website, the PAC Education program: pacep.org, the proceduresconsult.com website (via the BioMed Library), the SCORE website surgicalcore.org/ and other tools available to study topics related to critical care.
- The resident must view the SICU Central Line Course Curriculum on the trauma.ucsd.edu site and pass the on-line test.
- The resident must prepare for and attend daily ICU attending rounds.
- The resident must present a 20 minute seminar with a one-page handout on a topic assigned from the SICU seminar topics list at least twice per month.
E. Systems-Based Practice
- The resident should be able to communicate effectively with patients, families, nurses, and allied health care personnel.
- The resident should be able to use appropriate consult services to improve care of patients in the intensive care unit.
- The resident will participate in the coordination of the rehabilitation of the critically ill patient.
- The resident will demonstrate knowledge of cost-effective critical care.
- The resident will learn how to be an advocate for critically ill patients within the health care system.
- The resident will refer critically ill patients to appropriate practitioners and agencies.
- The resident will facilitate the timely discharge and/or transfer of critically ill patients.
- The resident should function as a member of the ICU team and act as a liaison with each patient’s home service to communicate patient progress and plans for care by the ICU team.
- The resident should relate concerns and advice from the patient’s home team to the ICU service.
- The resident should be able to work with family to respect patient’s end of life wishes, including withdrawal of care in a dignified manner.
- The resident will support and participate in SICU Quality Improvement Programs.
- Develop a sensitivity of the unique stresses placed on families of patients in the SICU.
- Demonstrate an unselfish regard for the welfare of SICU patients.
- Demonstrate a commitment to carrying out professional responsibilities and adherence to ethical principles.
- Demonstrate firm adherence to a code of moral and ethical values.
- Be reliable, punctual and accountable for own actions.
- Effectively deal with dissatisfied patients and their families.
- Effectively deal with substance abuse patients and their families.
- Effectively deal with indigent patients and their families.
- Understand the benefits and functionality of multidisciplinary health care teams and use a professional and appropriate demeanor when with fellow team members and with other disciplines.
- Keep close track of work hours and report risk of hour overages or absences promptly.
- Guide and educate peers and junior residents and students in critical care topics.
Perform through and careful handovers of the Service to team mates when starting or ending duties each day to ensure patient safety and continuity of care.