Chris Miller in classroom

Critical Care

Breadcrumb

Organization and Course Description

The critical care selective will expose the student to a broad experience in the care of critically ill patients. The clinical site will be a licensed critical care unit (e.g., a medical ICU, surgical ICU, cardiac care unit, neonatal ICU, pediatric ICU, or similar unit). Students will be able to identify preferences for sites from a list of approved critical care rotations and will be assigned to sites based on their preferences and pedagogical and organizational needs. It will be a four-week rotation, and students will be expected to attend clinical duties full time (minimum 36 hours per week). Overnight and/or call duties may vary depending on the clinical site.

Students will be required to attend weekly four-hour Thursday afternoon group learning sessions at the UC Riverside School of Medicine main campus. There will also be a group session on the first day of the rotation at the school for an introduction to the rotation. These can be attended virtually or in person.

Students are required to complete a Critical Care Procedure and Diagnosis Log during the rotation (see below for details), and log duty hours.

Access to a series of online learning modules will be provided to each student, and completion of all modules is required by the end of the rotation. Certain modules will be required to be completed by a certain date as preparation for the on campus didactic sessions (e.g., completion of the online shock module prior to the teaching session on shock). Other adjunctive materials will be provided for various didactic sessions as well (such as slide decks, articles, etc.) and students will be expected to have reviewed these materials prior to specific sessions.

In addition, one session will focus on debriefing regarding difficult patient experiences, and students will be required to complete a reflective writing assignment prior to the session.

Finally, each student will be required to research and present a 20-30 minute presentation on a relevant critical care topic during the final academic session of the rotation. The presentation will be expected to be focused, evidence-based, and to draw and synthesize information from the primary literature. The presentation should cover core physiological and background information, current best practices, current research directions, and future directions for clinical care and research. It is strongly suggested that you have your presentation reviewed by one of your clinical faculty and/or the selective director prior to presentation for feedback.


Course Objectives

Educational Program Objectives

As approved by the general faculty, the Medical Education Committee has established educational program objectives for the program leading to the M.D. degree. The Educational Program Objectives are comprised of competencies and the measurable objectives by which attainment of each competency can be assessed. The full text of the University of California, Riverside School of Medicine Educational Program Objectives (EPO) can be accessed here.

EPO competency areas referenced:

  • Patient Care (PC)
  • Knowledge for Practice (KP)
  • Practice-Base Learning and Improvement (PBLI)
  • Interpersonal and Communication Skills (ICS)
  • Professionalism (P); Systems-Based Practice (SBP)
  • Interprofessional Collaboration (IPC)
  • Personal and Professional Development (PPD)
Critical Care Selective Objectives

All objectives are followed by the EPOs to which they pertain.

  • Perform and document a complete history and physical exam on the critically ill patient; interpret laboratory and other pertinent data; and provide an assessment and critical care treatment plan (PC 3, 5-7, 9; KP 1-6; PBLI 1-4, 6-8, 11; ICS 1,3, 4-6; P 1,2,4; SBP 1-5; IPC 1-5; PPD 5-9).
  • Provide 24-hour patient summaries of critically ill patients at daily rounds, including previous and upcoming treatment plans (PC 3, 5-7, 9; KP 1-6; PBLI 1-4, 6-8, 11; ICS 1,3, 4-6; P 1,2,4; SBP 1-5; IPC 1-5; PPD 5-9).
  • Describe the management of ventilatory support measures in critically ill patients (including weaning) (PC 1, 3, 4-6; KP 1-4)
  • Design hemodynamic management and therapy in the critically ill patient, including the application and appropriate use of invasive monitoring modalities (PC 1, 3, 4-6 ; KP 1-4).
  • Identify strategies to diagnose and treat metabolic derangements in critically ill patients, including renal failure, electrolyte abnormalities, and acid-base abnormalities (PC 1, 3, 4-6 ; KP 1-4).
  • Outline the basic principles underlying the pharmacologic management of common ICU conditions (PC 1, 3-5, 7, 9; KP 1-6; SBP 1, 3, 5, 7 ; IPC 2-4;  PPD 6, 8, 9).
  • Outline reasonable strategies for identification of abnormalities of coagulation and the management of transfusions in critically ill patients (PC 1, 3-5, 7, 9; KP 1-6; SBP 1, 3, 5, 7 ; IPC 2-4;  PPD 6, 8, 9).
  • Provide examples of specific elements of neurocritical care and the management of traumatic brain injury, intracranial hemorrhage, and other intracranial pathology (PC 1, 3, 4-6 ; KP 1-4).
  • Describe the initial management of critical infectious processes, with emphasis on the prevention and treatment of nosocomial infections (PC 1, 3, 4-6 ; KP 1-4; PBLI 5,7; SBP 1,2,4-6; IPC 1,2,4).
  • Demonstrate sensitivity to the concerns of patients and their families surrounding critical illness, including quality of life and end of life issues (PC 1, 10-12 ; KP 6; PBLI 2,3,5,8; ICS 1,2,7,8; P 1-7; SBP 1,4; IPC 1-5;  PPD 1-5).
  • Demonstrate appreciation and respect for other professionals by appropriately responding to consultative and support services (PC 4,6,7,9; PBLI 2,4,11; ICS 1,3,4-6; P 1-7; SBP 1-7; IPC 1-5;  PPD 6-9).
  • Outline the evidence-based recommendations underlying at least one aspect of modern critical care management (PC 6; KP 1,7; PBLI 1-11; ICS 3-5; P 1; SBP 1,4,5,7; IPC 2,4; PPD 2,4,6,9).

Academic Participation Requirements

Director Brigham C. Willis, M.D.

Attendance
Students are directed to the UCR SOM attendance policy in the Student Handbook.

Students are expected to attend a minimum of at least 20 “shifts” at their clinical site during their four week rotation. A student may not miss more than three days of a rotation due to illness, emergency, or an approved absence.  A longer absence must be remediated in consultation with the selective director and medical education or the rotation must be repeated.

Interactive Learning Sessions
UCR SOM or Virtual

Academic Half-day – Thursday afternoons (See session list and specific requirements below.) All sessions are mandatory. There is also an orientation on the first day of the rotation. Dismissal to sites by 10 a.m.
Clinical Site Requirements

Call Schedule:
All students are expected to participate in some type of after-hours experience. While students are not required to take overnight call, such call may be a part of the schedule at a given site, within the limits set by duty hour rules. The schedule will vary according to the site. Specific expectations and schedules will be determined by the site director.

Dress Code:
Professional attire is expected when you are interacting with patients in the inpatient and outpatient clinical setting. Examples of appropriate dress include trousers and a button-down shirt for men and slacks/skirt and a blouse for women. White coats and name badges are expected in both the inpatient and outpatient setting. Scrubs are acceptable based on site director preference. Closed toe shoes are necessary for your protection.  

Professionalism and Privacy Practices Issues:  
Cell phones and other electronic devices should be used appropriately.  Photographs of patients are not permitted without express, written permission.  When in lectures, rounds and other learning environments, please pay attention and limit the use of these devices.

You are responsible for learning the privacy practices for each site at which you work. The attending and/or site coordinator will be familiar with these and can provide guidance.  Always keep HIPPA in mind and observe all policies and practices.

Suggested Texts
Some readings from the suggested texts will be required prior to designated academic sessions

Required Online Modules

Virtual Critical Care Rounds

Provided through the Society for Critical Care Medicine (SCCM) website. Students will be expected to complete all modules in either the VCCR Adult I or VCCR Pediatric II series. Each student will be provided with a login and password for both series, and progress and completion dates will be monitored by the selective director. Certain modules will need to be completed by certain dates (e.g., the module on Shock will need to be completed prior to the on-campus didactic session on shock).

VCCR Access: https://www.sccm.org/Education-Center

Reflective Writing Assignments Students will be expected to complete a reflective writing assignment related to their experiences on the rotation (or related to experiences with critically ill patients on other clerkships or rotations) prior to the on-campus session entitled “Debriefing on Experiences in Critical Illness.” The reflections must be a minimum of one page in length (standard margins, font no larger than 12 point), but the assignments are expected to be thoughtful and thorough. These will not be graded for content, and will not be read by the facilitators before the session, but they will serve to inform your discussion and allow you to thoughtfully reflect on your experiences prior to the discussion. Assignments should be submitted online. Please also print them out or bring an e-copy to the session. Also see Reflective Writing Grading Rubric.
Final Presentation Each student will be required to research and present a 20-30 minute presentation on a relevant critical care topic during the final academic session of the rotation. The presentation will be expected to be focused, evidence-based, and to draw and synthesize information from the primary literature. The presentation should cover core physiological and background information, current best practices, current research directions, and future directions for clinical care and research. See Presentation Grading Rubric.
Patient Experience and Procedure Logs Students are expected to complete experiential and procedure tracking logs to ensure a complete educational experience in critical care.
Duty Hours Students are expected to complete duty hour logs per UCR SOM policy and report violations to the selective director.
Patient Experience and Procedure Logs

For this selective, medical students are expected to encounter the following types of patients and clinical conditions and have the indicated level of student responsibility.  

The standardized levels of student responsibility include:

  1. Observe and Discuss: This may include observing another member of the team interview a patient, perform a procedure or physical exam, etc. and discussion of the case, condition or other relevant components.
  2. Actively Participate in Care: This category indicates more active responsibility for the patient, such as performing a physical exam and workup, entering progress notes or H&Ps, presenting the patient on rounds, as scrubbing into a case or counseling or discussing prevention with the patient.
  3. Perform Procedure: This is defined as the student performing the procedure with supervision.  

The following steps should be taken for alternative experiences:

  1. The student will notify the selective director that an alternative experience is needed for a procedure or diagnoses one week prior to the end of the selective.
  2. An approved alternative experience/requirement is completed.
Type of Patient/Clinical Conditions Level of Student Responsibility Alternative Experience

Shock

Active participation in care https://www.khanacademy.org/science/health-and-medicine/circulatory-system-diseases/shock/v/septic-shock-pathophysiology-and-symptoms
Management of arrhythmias Active participation in care Review >5 videos on arrhythmias on Kham Academy:
https://www.khanacademy.org/science/health-and-medicine/circulatory-system-diseases/dysrhythmias-and-tachycardias/v/normal-sinus-rhythm-on-ecg
Respiratory failure Active participation in care

https://youtu.be/gk_Qf-JAL84

Watch all five parts of the video

Electrolyte derangements Active participation in care Review ILM by Dr. Brigham Willis (posted to course website)
Transfusion of blood products Active participation in care https://youtu.be/tLCl04RNVMQ
Sepsis Active participation in care https://www.khanacademy.org/science/health-and-medicine/circulatory-system-diseases/shock/v/sepsis-sirs-mods
Healthcare associated infection Active participation in care https://youtu.be/-FfMCv8FUXI
Cardiopulmonary interactions - preload limitation / augmentation by intrathoracic pressure changes Observe and discuss

Read: Stigall WL, Willis BC. Mechanical Ventilation, Cardiopulmonary Interactions, and Pulmonary Issues in Children with Critical Cardiac Disease, in E.M. da Cruz e al. (Eds.), Pediatric and Congenital Cardiology, Cardiac Surgery and Intensive Care, Springer-Verlag London

(posted to course website)

Cardiopulmonary interactions - left ventricular afterload modulation by intrathoracic pressure changes Observe and discuss

Read: Stigall WL, Willis BC. Mechanical Ventilation, Cardiopulmonary Interactions, and Pulmonary Issues in Children with Critical Cardiac Disease, in E.M. da Cruz e al. (Eds.), Pediatric and Congenital Cardiology, Cardiac Surgery and Intensive Care, Springer-Verlag London

(posted to course website)

Cardiopulmonary interactions - effect of intrathoracic pressure changes and ventilation on right ventricular performance and pulmonary vascular resistance Observe and discuss

Read: Stigall WL, Willis BC. Mechanical Ventilation, Cardiopulmonary Interactions, and Pulmonary Issues in Children with Critical Cardiac Disease, in E.M. da Cruz e al. (Eds.), Pediatric and Congenital Cardiology, Cardiac Surgery and Intensive Care, Springer-Verlag London

(posted to course website)

Assessment of coagulopathy Active participation in care https://www.khanacademy.org/science/health-and-medicine/advanced-hematologic-system/bleeding-and-impaired-hemostasis/v/introduction-to-hemostasis
Management of elevated intracranial pressure Active participation in care https://youtu.be/6aqklopZheU
Acute kidney injury Active participation in care https://youtu.be/DecCzLpjAHw

Skills and Procedures Expected Level of Student Responsibility Alternative Requirements
ABG Interpretation Active participation in care ILM on ABG interpretation
Arterial line placement Observe and discuss NEJM Videos in Clinical Medicine - Arterial Line Placement
Chest X-ray interpretation Perform procedure https://internalmedicine.med.uky.edu/im-chest-x-ray-tutorial
ECG Interpretation Perform procedure https://ecg.utah.edu/
Endotracheal intubation Observe and discuss NEJM Videos in Clinical Medicine - Endotracheal Intubation
Management of mechanical ventilation Active participation in care

Clinical cases in mechanical ventilation online:

https://courses.washington.edu/med610/mechanicalventilation/cases.html

Obtain informed consent Observe and discuss UpToDate: Informed Consent
Central venous line placement Observe and discuss NEJM Videos in Clinical Medicine - Central Venous Access
Thoracentesis / thoracostomy Observe and discuss NEJM Videos in Clinical Medicine - Thoracentesis

Didactic/Interactive Learning Sessions

All sessions will be case-based and entirely interactive / simulation based. It is intended that these small-group learning sessions be based on group participation, discussion, and active learning. As such, it is critical that students come to the on-campus sessions prepared by having reviewed and / or completed the specified independent learning materials. The background materials are intended to give the student enough knowledge, supplemented by what they see and learn clinically, to engage in a reasonable discussion of related clinical cases. Students WILL be expected to have a basic understanding of the topics to be covered and to participate in an intelligent discussion of the cases presented. Small group facilitators will be instructed to actively assess the level of preparedness of each student as a part of the small group participation assessments.

All objectives and supplementary materials for each session are located on the Critical Care Selective folder in iLearn or Canvas.

Orientation (Day 1)
Introduction to Critical Care
Week 1
Mechanical Ventilation
  • Required online module(s): VCCR Adult Module “Basic Mechanical Ventilation.”
  • Required readings / materials:
    • Marino, Section 8, Ch. 25-30; or Fuhrman, Ch 49
    • Article: ARDSNet. VENTILATION WITH LOWER TIDAL VOLUMES AS COMPARED WITH TRADITIONAL TIDAL VOLUMES FOR ACUTE LUNG INJURY AND THE ACUTE RESPIRATORY DISTRESS SYNDROME. NEJM, 2000. 342 (18): 1301-1308.
  • OpenPediatrics Mechanical Ventilation Simulator (all modules)
Shock
  • Required online module(s): VCCR Adult Module “Shock” / VCCR Pediatric Module “Shock: Assessment and Therapy.”
  • Required readings / materials: Marino, Ch 9, 10, and 14; or Fuhrman, Ch. 29.
Week 2
Pharmacologic Management of the Critically Ill Patient
  • Required online module(s): VCCR Adult Module “Pharmacology and Pharmacokinetics.”
  • Required readings / materials: Marino, Ch 51-53; or Fuhrman Ch 110-112.
Neuro and Cardiac critical Care
  • Required online module(s):
    • VCCR Pediatric Module “Traumatic Brain Injury.”
    • VCCR Adult Module “Arrhythmias.”
    • VCCR Adult Module “Advanced Cardiovascular Life Support and Rapid Response Team.”
  • Required readings / materials: Marino 15-17; Marino Ch 44, 45, and 46 or Fuhrman Ch 50, 52, and 53.
Transfusion Medicine in Critical Care
  • Required online module(s): VCCR Adult Module “Transfusion Medicine in the ICU.”
  • Article: Reikvam et al. Thromboelastography. Transfusion and Apheresis Science. 2009. 119-123. doi:10.1016/j.transci.2009.01.019
  • Online Activities: VCCR Adult Module “Transfusion Medicine in the ICU.”
  • Thromboelastogram video: https://www.youtube.com/watch?v=-4d9buDGXAo
  • Required readings / materials: Marino Ch 18 and 19; or Fuhrman Ch 75.
Week 3
Ethics of Critical Care
End-of-life issues, Culturally Competent Care, and Death and Critical Illness Notification to Families
  • Required online module(s): VCCR Adult Module “Palliative Care in the ICU: An Integrated Approach”
  • Required readings/materials:
    • "GRIEVING: Death Notification Skills and Applications for Fourth-Year Medical Students”. Hobgood, et al. Teaching and Learning in Medicine, 21(3): 207-219. 2009.
    • SPIKES and SPAM format for Bad News (on iLearn).
    • Choi and Murn. Palliative Care in the ICU Chapter (on iLearn) R. C. Hyzy, J. McSparron (eds.), Evidence-Based Critical Care, https://doi.org/10.1007/978-3-030-26710-0_107.
Week 4
Debriefing on Experiences in Critical Illness
  • Required preparation: Completion of reflective writing assignment.
Evidence in Critical Care: Student Presentations on Critical Care Topics

Selective Specific Assessment and Evaluation Process

Assessment is the mechanism used to measure progress in learning over a given period of time.  Please refer to the Assessment Flow Diagram in Appendix A and the Critical Care Medicine Selective Assessment Process in Appendix C for additional details.

A mid-rotation formative assessment for each student is strongly suggested. This is scheduled at a specific time and students are required to pro-actively plan on timely completion in discussion with their faculty member.  If there are identified challenges, the Selective Director should be notified as soon as possible.  The mid-rotation assessment will be completed by a faculty member (designated by the site director or selective director) at the student’s primary clinical site. Student progress, achievements, strengths, weaknesses, and areas for improvement should be discussed. These are not summative and do not require a form to be completed, but are intended to guide the student in their learning and development on the rotation.

Additionally, throughout the four weeks of the selective, faculty and residents engaged in student teaching and supervision will provide formative feedback in a variety of formats (e.g. review of progress notes, H&P’s, direct observation forms, informal verbal feedback and written narratives) that may be communicated in writing or verbally.  The purpose of this feedback is to identify strengths and opportunities for improvement.  Any significant deficiencies or concern should be communicated to the selective and/or site director with written documentation that the feedback has been provided to the student. 

A minimum of one clinical End of Rotation Assessment per rotation will be submitted for the student's clinical grade by the site director or their appointee.

Where applicable, multiple End of Rotation Assessments will be considered in the clinical grade calculation (see below under “grading”) providing each assessor has had significant interaction with the student. In the instance that only one End of Rotation Assessment is submitted, it will be a collaborative assessment from the preceptors who had significant interaction (as defined by the selective director) with the student. Where only a single faculty member has been assigned to work with a student, this faculty member will provide an assessment for the student. 

In addition, a student may request that the site director or designee seek assessment input from faculty the student feels have had significant interaction with that student.  Additional assessors (such as residents, fellows, or other faculty) may use the Critical Care Selective Supplementary Feedback Form (PRIME) for such feedback (see below).

A Selective Director Final Assessment form will be completed by the selective director.

All End of Rotation Assessment Forms and the Selective Director Final Competency Assessment Form may be viewed by students.

Student Evaluation of the Selective

Student evaluation of the selective is required. The student must complete the evaluation in the required time frame and submit the document on line. All comments will be expected to model constructive feedback, and must contain references and comments to specific behaviors and/or events (positive or negative).  


Composite Grade Calculation

Clinical Performance

Clinical performance will account for 50% of the composite score and is assessed using the End of Rotation Assessment forms.  The selective director will review and include all of the available End of Rotation Assessments to complete the Selective Final Grade Form. Students may also distribute and submit feedback from residents, fellows, and other faculty with whom they have had significant contact using the Critical Care Selective Feedback (PRIME) Form.

Non-clinical performance

Each of the criteria and components below will be compiled by the selective director to determine the non-clinical grade:

Participation in small group learning sessions 20 points possible
Aggregate of small group facilitator assessments (see attached facilitator assessment form in appendix); satisfactory participation in all sessions will earn 100% of points (includes completion of auxiliary learning items prior to sessions (e.g., modules or reflective writing assignments)).

Successful completion of online learning modules 28 points possible
100% awarded for completion of all modules by designated dates; three points deducted per module late or not completed.

Completion of Critical Care Procedure and Diagnosis Log and Duty Hour Logs 20 points possible
100% awarded for on-time completion of logs; 10 points deducted for late completion of either log.

Final presentation 32 points possible
See grading rubric for breakdown of points.

For the non-clinical assessment, a percentage will be calculated based on the students total points achieved, divided by the total possible (100)
For the non-clinical assessment (combining participation, online learning modules, procedure and diagnosis log, and final presentations), the following cutoffs will be used:

  • 90-100%  - Honors
  • 80-90% - High Pass
  • 70-80% - Pass
  • <70%  - Fail
Composite Grade

The grade will be a composite grade, using the clinical performance, completion of required supplementary activities, and participation in on-campus academic activities.  The composite grade will be divided into four categories:  Honors, High Pass, Pass, or Fail (H, HP, P, or F).  The following guide will be used in determining the final grade:

Clinical Grade Non-clinical Grade Final Grade
Honors Honors Honors
Honors High Pass Honors
High Pass Honors Honors
Honors Pass High Pass
High Pass High Pass High Pass
High Pass Pass High Pass
Pass Honors High Pass
Pass High Pass  Pass
Pass Pass Pass
Fail (Any Grade) Fail
(Any Grade) Fail Fail

Failure of the selective will require the selective to be repeated in its entirety.

Students are to have the following requirements completed by the defined deadline.  In the absence of a significant extenuating circumstance determined by the Selective Director (e.g. software issues, illness, etc.) that preclude completion within the defined deadline, the medical student will receive a grade no higher than Pass once these assignments are completed:

Standard Requirements
  • Duty hour logging (at least 3 days prior to the end of the selective)
  • Required online module completion (at least 3 days prior to the end of the selective; however, a failure to complete specific modules prior to specific linked on-campus didactic sessions will result in a deduction of points – see above)
  • Completion of reflective writing assignments (at least 3 days prior to the end of the selective; however, a failure to complete the writing assignments prior to the debriefing on-campus session will result in a deduction of points – see above)
  • Participation in all didactic sessions
  • Satisfactory completion of final presentation
  • End of the selective evaluations  

The student will fail the selective if they receive a failing score on one of any of the following:

  • Failure of the clinical performance section of the composite
  • Achieve a score of less than 60% from the “other” requirements
  • Total composite score of Fail

Comments: The selective director will complete a Final Grade Form indicating the individual and composite components of the grade. This is the final grade/evaluation form for the student that contains the final recorded transcript grade, comments from all of the End of Rotation assessments and a separate box with the summarized final comments which will be included in the MSPE (dean’s letter). The summary final comments are generally not a direct cut and paste but rather a sample summary determined by the selective director. The selective directors have the right to include or not include comments based on their interpretation of which comments best summarize the student’s performance over the entirety of the selective. Students may not pick specific, comments to be included or excluded in their narrative grade form. Students do not grade or summarize their own performance. Any concerns regarding narrative comments may be addressed to the selective director or senior associate dean of medical education.


Critical Care Assessment Forms and Grading Rubrics