Intensive Care Unit -- Information for Residents
Welcome to the ICU and the Critical Care Service (CCS)! Please read this information packet
before you start your rotation; it will help answer questions about your ICU rotation. Please ask
additional questions or bring up concerns you may have about your rotation at any time.
The Intensive Care Unit at Dartmouth-Hitchcock Medical Center is a 26 bed multi-specialty unit,
caring for adult patients from all medical and surgical services.
The ICU environment provides intensive treatment for critically ill patients on a concentrated
and continuous basis. Patients are generally admitted because of the need for close observation,
vasoactive drugs, aggressive pulmonary care, or mechanical ventilation. The ICU provides
physiological monitoring equipment, a highly skilled nursing staff, and a readily available
Humanistic considerations of the patient and family provide the framework for medical and
nursing decisions made in the ICU.
The multidisciplinary ICU of DHMC functions according to a collaborative model. For most
medical patients, the critical care attending serves as the primary attending (attending of record).
For surgical patients and some medical patients (e.g. bone marrow transplant patient), the critical
care attending serves as the co-attending physician of record.
Critical Care Attendings include:
David Axelrod, MD – Transplant Surgery
Perry Ball, MD - Neurosurgery
Kenneth Burchard, MD - General Surgery, Associate Director, ICU
Howard Corwin, MD - Medical Director, ICU
Peter DeLong, MD - Pulmonary Medicine, Associate Director, ICU
William Dewhirst, MD - Anesthesiology, Associate Director, ICU
D. David Glass, MD - Anesthesiology, Chair, Dept of Anesthesiology
Rajan Gupta, MD – General Surgery
Paul Kispert, MD - General Surgery
Harold Manning, MD - Pulmonary Medicine
Thomas Prendergast, MD - Pulmonary Medicine
Timothy Quill, MD - Anesthesiology
Athos J. Rassias, MD - Anesthesiology, Associate Director, ICU
Peggy Simon, MD - Pulmonary Medicine
Stephen Surgenor, MD. – Anesthesiology, Chief of Critical Care Medicine
The critical care attendings generally rotate through the ICU in 1 to 2 week blocks of time.
House Officers and CCS Fellows in the ICU are divided into two Teams, Red and Blue. Each
Team works under the direction of one CCS attending physician. A CCS Fellow is the senior
House Officer on each Team. Each Team is comprised of Four House Officers from the
Departments of Surgery, Internal Medicine, and Anesthesiology, as well as residents from the
Departments of Obstetrics, Neurosurgery, and Orthopedics.
ICU Morning Rounds:
Morning rounds in the ICU begin at 8:00 AM, 7 days a week, including holidays.
The task of pre-rounding and presenting the patients is shared each day by the available
residents. The more senior residents on each team are responsible for ensuring fair distribution
of patients to each resident on the team. Although individual attendings may vary in their
preferences, a general framework for presenting is as follows:
1. Identifying statement: to remind everyone who the patient is (we don't need a recital of
the history on a daily basis); e.g.: 59 y.o. with renal failure and ARDS s/p resection
abdominal aortic aneurysm.
2. Events past 24 hours: these should be significant events (such as bleeding, need for re-
intubation, serious arrythmias, new onset seizures, hypotension, etc.) and not simply a
rehash of all the routine sorts of things that took place the previous day (i.e. Mr. T
got 40 meq of potassium for a K of 3.2).
3. Review of current medications, particularly emphasizing:
A. Antibiotics: what day of which antibiotics, for what reason:
e.g. day 5 out of 10 of ampicillin and gentamycin for E. coli UTI.
B. Steroids (how long, plan to taper?)
C. GI and DVT prophylaxis
E. Dose adjustments for renal, hepatic disease
4. Nutrition: what, if anything, the patient is getting.
5. Physical exam: specific vital signs will usually be of interest. Include only positive
findings or very pertinent negatives (e.g. an asthmatic now free of wheezing)
6. Data: ICU patients generate lots of data. Rounds can become a lengthy recital of
numbers, particularly when the ICU is busy. Listening to a long list of numbers gets
boring rather quickly, and the unimportant numbers often distract attention from the
important numbers and the "big picture". To make rounds both more palatable and more
useful (and even more interesting and enjoyable), we need to streamline the flow of
information. The mere fact that a piece of data is available does not mean that it needs to
be presented on rounds (likewise, just because you examined the entire patient does not
mean you need to describe the entire physical exam on rounds). Furthermore, if
occasionally you do not mention something that we would like to know, we can always
ask you for the specific information. We have to depend on you to distill all the available
data and information into the essentials for rounds, thus we depend on your ability to
distinguish the important from the less important. Present only the data that is relevant
for that particular patient. We do not need to know the exact I's and O's, NG tube
drainage, platelet count, LFT's, phosphate, etc. for every patient.
A. Net fluid balance (and change in weight relative to previous day and
admission) is often more informative than the exact I's and O's.
B. We almost always need to know most recent ventilator settings and
ABG (if available).
C. Summary of hemodynamics, highlighting trends and changes (e.g.
“the cardiac index was averaging about 1.6, and increased to around
2.4 after dobutamine was begun”).
D. Labs: if normal, just say so unless there is some overriding reason to
report the exact value. If abnormal, it's always helpful to put things in
perspective by comparison with previous values (e.g. creat 2.6, up from
7. Summary of problems and plans:
A. Review the big picture: what is the underlying process, prognosis, etc.
B. Outline each of the patient's active problems. Include an assessment and
plan. Come up with a specific plan. Do not just say "we can try weaning
again today". Instead, state specifically what you think should be done
with respect to each of the problems (e.g. "spontaneous breathing trial;
extubate if he does well for 30 minutes"). This is a chance to try to make
sure things get done the way you think they should.
8. Be concise: The above guidelines apply to established ICU patients.
A. New patients will require a more detailed presentation, particularly of the
B. During rounds, the team will arrive at the plan of care for each patient for
the day. Appropriate orders will be written at this time.
9. Computerized daily progress notes:
A. All progress notes must be computerized notes entered in CIS
B. These notes should contain events and data from the previous 24 hours;
the notes no longer need to be printed and placed in the patients’ chart.
C. Each resident is given priority use of a rolling laptop unit (one unit per
team) to complete his/her daily progress notes. The mobile units must be
charged appropriately, so please plug mobile units into outlets whenever
possible (battery life is about 2 hours).
D. Every effort has been made to make these notes as similar to the previous
written progress notes as possible. The notes should be started during the
on-call day and largely completed before rounds (a few details, such as the
CXR findings, may not be filled in until after rounds).
E. Additional notes or addendums should be written to document important
changes and major diagnostic and/or therapeutic interventions.
10. Important caveats: Many physicians make frequent use of “cutting and pasting.”
Although this often saves time, it also often leads to the incorporation of outdated or
incorrect information in the patient’s medical record (e.g. it may not reflect changes in a
patient’s medications, ventilator settings, etc.). Therefore, if you cut and paste when
putting your notes together, it is your responsibility to make sure that any all the
information incorporated in your notes is current and accurate.
Because notes are usually started the day prior to rounds, the “Encounter Date” in CIS
must be changed to the actual rounding date before signing. For example, if you are on
call Weds and begin your note that day but complete and sign it after rounds the
following day (Thursday), the computer will list Wednesday as the Encounter Date. You
must manually change the date to reflect the date that you are finalizing and signing the
Each weekday at 10:00 AM - 10:30 AM (depending on the ICU census), both teams gather in the
Department of Radiology with an attending radiologist to review and discuss the most recent
plain roentgenograms, CT scans, etc. that have been performed on their patients.
Each weekday at 11:15 AM there will be a Critical Care Lecture given in the ICU Conference
Room for the House Officers in the ICU. The lectures encompass a wide variety of basic Critical
Care topics. All House Officers in the ICU are required to attend these lectures. Please sign in on
the attendance sheet. Routine patient care issues should not interfere with attendance at
conference. Such issues may be dealt with by the Fellow and/or Attending while you are at
conference. You should NOT start procedures, such as routine line changes, immediately before
conference. In the event of an emergency, page 2419. (Saturday on-call resident does not attend
Thursday conference – they are “excused”.)
In addition to the didactic sessions, there are two loose-leaf folders that contain articles on a
variety of critical care topics. The articles are of two types: recent, review articles that provide a
nice overview of important topics in critical care medicine and original papers that have
important implications for the treatment of some or many of our ICU patients. Please do NOT
remove the articles or folders from the ICU. If you want copies of any of the articles, most can
be downloaded electronically.
At 1:30 PM Monday through Friday there will be Hand-off Report in the ICU conference room.
During this report, the consult service will sign over any pertinent patient issues to the on-call
fellow and staff. Blue and Red teams will report on remaining patient activities such as
procedures, studies that need follow up, and discharges. Follow up on any discharged patients of
interest can be discussed. The intent of the hand-off is to communicate key issues to the on-call
providers. (Residents that are post-call, day-off, or have clinic are excused form Hand-off
The Call Schedule:
The Call Schedule is posted on the Critical Care Web page. It is also posted in the ICU Chart
Room. House Officers in the ICU are on-call every fourth day. The general outline
for the four-day rotation is as follows:
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
R1 On Call Post Call Swing Early Round/
On Call Post Call “Off”
R2 Early Round/
On Call Post Call “Off” Early Round On Call Post Call
R3 Swing Early Round/
On Call Post Call “Off” Early Round On Call
R4 Post Call Swing Early Round/
On Call Post Call “Off” Early Round
Call begins at 8:00 AM and ends at 8:00 AM the following day. The post-call House Officer is
expected to stay for radiology rounds and for the 11:15 AM Lecture. The post-call resident my
leave after lecture if clinical duties have been completed.
The general outline for the four-day rotation is as follows:
Day 1 (Call Day): 8:00 AM - 8:00 AM
Call begins at 8:00 AM and ends at 8:00 AM the following day. The resident is
responsible for new admissions after the morning lecture Monday-Friday and throughout
the day on weekends. The on-call resident is responsible for coverage of the entire
service at night but will write a maximum of 10 inpatient notes for the following day’s
rounds. The remaining notes will be written and presented by the “early
rounder” (Day 4, see below)
Day 2 (Post-Call Day): Leave after 11:15 AM resident lecture if clinical duties have been
Day 3 (Swing Day): 8:00 AM – 4:00 PM
There is no admitting responsibility for the “swing” resident. Responsibilities include:
attendance at morning rounds, radiology rounds, and the 11:15 AM lecture. The swing
resident should also be available to assist the on-call resident with the completion of any
planned procedures, lines, or other tasks on the patients on the team.
Day 4 (Early Round): 7:00 AM – 5:00 PM, Monday-Friday,
7:00 AM – 12 noon, Saturday and Sunday.
In order to reduce the burden of rounding for the post-call resident, the “early round”
resident will arrive before rounds to help write notes and assist the resident who is post-
call in preparing for rounds. The number of patients that the “early rounder” will be
responsible for will vary as a function of the ICU census. Whenever the census on the
team is greater than 10 patients, the early rounder is expected to pre-round and write
notes on all patients that the post-call resident has not seen. Ideally the “early round”
resident will take responsibility for the more chronic (i.e.less acute) patients who are less
likely to have significant changes occur overnight. When the team census is less than 10
patients, the “early rounder” may help the post-call resident in general preparations for
rounds. The early rounder must be available until 5:00 PM, Monday – Friday, and until
12:00 noon, Saturday and Sunday unless they have clinic.
• During your CCS rotation, all clinical time must be dedicated to the ICU. You are
expected to be present in the Unit at all times in order to provide emergent medical
care. If there is a schedule conflict, any changes must be approved by Dr. Peter
• Some residents may have other responsibilities (e.g. continuity clinic) that require their
absence from the ICU in the afternoon. Residents with clinic or other clinical
responsibilities may leave after the morning lecture.
• The House Officer on-call the last day of the month will stay for ICU rounds the next
morning (the first day of the new month).
Each resident is given 1 day per week completely free of all patient care responsibility. When a
swing day falls on a Thursday, Friday, Saturday, Sunday, or holiday the resident is given
the entire day off (holidays = July 4, Labor Day, Thanksgiving Day, Christmas Eve Day,
Christmas Day, New Year’s Eve Day, New Year’s Day, President’s Day, and Memorial Day).
Clinical Back Up:
The purpose of an academic ICU is to provide the highest possible level of patient care.
Commensurate with this goal is the desire to foster learning. Hence, as a physician-in-training,
you are expected to increase your knowledge base, and learn from your experiences. Reading,
especially when time allows during your short-call and swing days, is expected.
As a physician-in-training, you are not expected to be fully competent in Critical Care Medicine.
You should not make clinical decisions or perform clinical procedures beyond your level of
training without consulting those physicians who are your clinical back up. The CCS Fellow and
Attending are on-call 24 hours a day and are dedicated to Critical Care Medicine, patient
care, and education. You should feel free to call them; indeed, you are expected to notify them of
any serious changes in a patient’s condition.
For patients on surgical services, it should be remembered that the House Staff caring for the
patient prior to ICU admission have been closely following their course. Consequently, you
should feel free to contact the senior House Officers of these services with patient questions at
any time. The chief surgical resident on the general surgery consult service is expected to be
available 24 hours a day for ICU problems. He or she is to be notified of unexpected changes in
condition. Some examples of clinical changes that should prompt notification of the surgical
• New fever
• New hypotension
• New (or accelerating) vasopressor or fluid requirement
• Drop in hemoglobin or other evidence of bleeding
• Significant alteration in mental/neurological status
• Need for major diagnostic study (e.g. CT, MRI, angiogram, etc.)
The bottom line: any time you are unsure of what you’re doing, ASK for help. Do not do
anything of which you are not sure. And when there are changes in a patient’s clinical status,
err on the side of over-notification of the primary service.
When changes occur in a patient’s condition, it is the CCS House Officer’s responsibility to
initiate emergent medical care. At the same time, it is crucial to communicate with the CCS
Fellow as well as with senior members of the patient’s primary service.
Ordering Labs or Diagnostic Studies:
AM labs are generally ordered the day/evening before on the standardized order sheet. The
House Officer on-call will fill out the Lab Order sheets for the next day’s AM labs.
Diagnostic studies such as CT scans, ultrasounds, echocardiograms, etc. can be ordered by the
ICU House Officer after discussion with either the CCS Fellow or Attending. Frequently
(especially on weekends), the Resident will need to call the appropriate department (e.g.
Radiology, Cardiology) to schedule and/or confirm these studies.
Code Status Determination:
The determination of a patient’s code status or a change in their code status only takes place after
the attending physician from the primary service or the CCS Attending has discussed these issues
with the patient or patient’s family. Frequently when code status issues are raised, a family
meeting will take place in which the patient’s family members get together with the primary
attending physician, CCS attending, any attendings from consulting services, fellow, resident,
and nursing staff involved in that patient’s care. The results of such discussions are to be
documented in the patient’s chart and the standard code status form filled out. This form is to be
signed by one of the attending physicians.
Transferring Patients In and Out of the ICU:
Patients may be transferred IN to the ICU from a variety of locations including: DHMC
Emergency Department, operating room, general medical or surgical wards, or another health
When a patient on a medical or surgical ward is deemed to need ICU care, the intern or resident
caring for that patient on the ward will call the CCS fellow or attending carrying the ICU
admission pager (#2419). The CCS fellow will evaluate the patient and determine if an
admission to the ICU is warranted. If the patient is transferred to the ICU, the House Officer on
the primary service should provide a transfer note that summarizes the patient’s major medical
problems and current events.
When transferring a patient OUT of the ICU, the primary service is contacted to confirm that the
transfer is agreed upon. When patients whose primary service is surgical (General Surgery or any
of the surgical subspecialties, including OB-GYN) are transferred out of the ICU, a resident on
that primary service will write the transfer orders. The ICU Resident does NOT need to write a
transfer note since the residents from the primary service will have continued to follow the
patient in the ICU. When a patient on the medicine service is to be transferred out of the ICU, the
accepting medical resident or attending should write the transfer orders, but the ICU Resident
MUST write a transfer note, since the medical house staff and medical attending will not have
followed the patient during the ICU stay. In those rare instances when a patient needs to be
transferred out of the ICU quickly (because of the immediate need for an ICU bed) and the
medical team is not immediately available, the ICU resident should let the accepting team know
the patient is being transferred and the ICU resident should write brief transfer orders to get the
patient to the floor. The ICU team should continue to provide care until the patient leaves the
For all patients transferred from the ICU to the medical service, the accepting medicine
resident or attending MUST be called (pager 2300) and notified that the patient is being
transferred to the medicine ward, and a verbal synopsis of the patient’s condition provided.
Procedures and documentation:
** All procedures, regardless of urgency are preceded by a time-out.**
Procedure notes should also be completed in CIS using the available templates. It is expected
that an attending will be present for procedures performed during the day. You may have to
discuss the timing of the procedure to have the attending present. Please forward a copy of your
computerized procedure note to the supervising attending.
Please note that there is no system to flag orders. After you write an order you are required to
discuss this with the patient’s bedside nurse.
The Nursing leadership staff is comprised of the following people:
Rose Morgan, RN - CCS Nursing Director
Deb Cofell, RN - Care Manager
Ingrid Mroz, RN - Clinical Nurse Specialist
Please feel free to bring any problems, questions or concerns that you might have about the
nursing care in the ICU to this group.
The Nursing Staff in the ICU is comprised of all RNs. The Nurses work primarily twelve-hour
shifts (7:00 AM - 7:00 PM and 7:00 PM - 7:00 AM), with each nurse responsible for the care of
one or two critically ill patients. In addition, there is a Charge Nurse (pager 9259) on each shift
to manage shift operational concerns. Questions or concerns about a patient should be directed to
the nurse caring for that patient.
Each patient cubicle is designed to provide all equipment necessary for routine bedside care.
Please familiarize yourself with the Green Cart in each room. It contains syringes, sterile
dressing and suture material, as well as many other supplies that you may need. There is also a
Unit Technician to assist you with obtaining additional equipment. The Unit Tech sits at the desk
in the Nurses' Station, and is cross-trained in secretarial duties and supply maintenance).
Each ICU Team has a Respiratory Therapist who rounds with the Team in the morning, and
helps care for the patients followed by that Team. The responsibilities of the therapists include
assisting the CCS Team in the management of patients on mechanical ventilation, administration
of bronchodilators and other respiratory treatment modalities, assistance at intubations and
extubations, and accompanying all critically ill patients during transport from the ICU.
A pharmacist frequently rounds with one or both of the ICU Teams each day. This person is
extremely knowledgeable and helpful with drug choices, dosage issues, and is readily available
For patients requiring parenteral nutrition, an experienced nutritionist is available for
consultation (both in the ICU and throughout the hospital). Orders for TPN must be written by
2:00 PM each day.
For patients receiving enteral nutrition, nutritionists are also available for consultation.
The ICU has unlimited visiting hours and you will notice patients’ family members and other
visitors coming and going throughout the day and night. In general, this is not a problem. We
only ask that patients’ families telephone the bedside RN prior to entering the ICU. Visitors are
usually very cooperative and understanding when asked to step out to the waiting room when a
patient needs to have a procedure or therapy performed.