ProlongedFieldCare.org – Improving Far Forward Care

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AAR MPT Rotation at the University Of Cincinnati Medical Center 12 Oct–04 Nov 2014The purpose of this medical proficiency training (MPT) hospital rotation was to identify gaps in previous training and education that relate to Prolonged Field Care (PFC). The rotation was based on working 12 hour shifts in the Surgical Intensive Care Unit (SICU) at the University of Cincinnati Medical Center with an experienced RN providing care to a single trauma patient who had arrived either during the shift or the night prior. This would allow observation and participation in the care of a patient from arrival in the Emergency Department (ED) through surgery, if required, and continue in the SICU the remainder of the shift and subsequent shifts as well. A trauma pager was issued in order to respond to trauma alerts as they arrived in the ED. The care given by multiple teams working together throughout the continuum of care was staggering. Past rotations focused on medics chasing procedures in various departments with patient care a byproduct of those short interactions. It was hypothesized that by remaining with the same patients throughout their stay, the discussions by staff, reasoning of procedures performed and all of the ancillary care that occurred would aid in furthering education and experience. A written journal was kept each shift to aid in remembering lessons learned for future recommendations for similar PFC rotations at this institution as well as others with a similar curriculum. Some of these lessons learned and recommendations will be underlined in the text so as not to lose context.Special Forces Medical Sergeants (SFMS) do not routinely provide medical care on a daily basis. Non-Trauma Modules, (NTMs) simulations, and short scenarios during tactical training are the primary methods for skills sustainment and retention of education. Every 4 years Medical Sergeants are required to rotate through a hospital for a period of 4 weeks. These MPT rotations vary greatly from hospital to hospital and are often personality driven, by either that of the medic or the hospital staff. A more aggressive and interested medic may have an entirely positive and productive rotation while another medic at the same hospital, perhaps on the same shifts, may not meet the requirements and goals by not asserting themselves and building the rapport and relationships required. Some residents and certainly many nurses are very territorial and protective of both the unit they work in, the patients they care for and the amount of work they do each shift. Helping out with the less-glamorous scut work definitely builds trust and confidence in a short amount of time with those who hold the keys to the rotation. This was always the case, no matter the unit or level of staff. Day one started like most other rotations with administrative requirements such as computer based training, badging and a quick tour. Access to the electronic medical record system used by the institution should be obtained if possible, even if read-only access is possible. Day one also included a quick scrub class given by an experienced OR nurse. This was key as future shifts would include scrubbing with both resident and attending physicians. This becomes a measure of competency which will either set the medic up for participation or merely observation. The medic should become very familiar with scrubbing procedures, moving through a crowded OR and donning both gloves and gowns and any other required personal protective equipment. Once scrubbing is done to satisfaction, time should be taken to find where required supplies are kept in the shelving such as gloves, foley catheters and anything else that will make the medic a helpful asset as opposed to an OR obstacle. From the very beginning of the first shift the medic should be fully prepared to explain who they are and what they are trying to accomplish and learn. SICU nursing staff met in a small conference room at the beginning of every shift making this a great opportunity to give a brief introduction of who you are and what you are doing in their unit. This also preempts the many duplicate questions sure to be asked down the line. This is not the time to be the secret squirrel or grey man. Many of the staff have never worked with military medics and will have no idea of scope of practice. For this reason it is also wise to keep the statement of understanding, scope of practice, goals of the rotation and shift as well as a procedure list with a journal and schedule in a notebook within arm’s reach at all times, all of which are included at the end of this document. It is also advised that you bring and use whatever flowchart the medic would be using during a real world PFC scenario in order to edit it as needed and gain familiarity to it. The SOU may be a required ‘inspectable item’ to have on person to identify the legal grounds of who the medic is and what they are doing in the hospital. This was never an issue throughout this author’s rotation. The first SICU nursing shift began immediately with an acutely ill stabbing victim who was on CRRT (a kind of portable bedside dialysis), the usual arterial lines and monitor, a ventilator and multiple drips going through electronic pumps as well as wound vacs placed during multiple previous surgeries. This was the most complicated and theoretically interesting patient in the pod (section of the unit). It was also the most overwhelming. Without the time taken with a proper orientation to the unit or pod an outsider could be more of a hindrance to the patient care and staff than expected. It is highly recommended that the first shift be spent entirely with the charge nurse just as other new nurses do on the first day/ orientation. This will allow you to become familiar with more of the staff, layout of the unit and most importantly where the supplies are kept in patient rooms and throughout the unit. General questions can then be answered before getting into the specifics of certain patients during subsequent shifts. The charge nurse also attends rounds in the conference room with both the trauma and ICU teams. Due to the sheer number of staff; 2 attendings, fellow, 5 residents, 5 nurses and 3 pharmacists, this should be an eye opening experience for the medic who is used to working alone and may be apprehensive to asking for help through outside telemedicine. This is another good time to introduce yourself and even entertain questions or give a quick presentation of your scope of practice if set up previously through the attending. Many patients require mechanical ventilation of some kind and the entirety of the second shift in the ICU, before being assigned to a nurse, should be one following a respiratory tech (RT) through his or her pod. The medic will experience many different patients requiring the spectrum of ventilation settings and applications. For this reason the medic who is not familiar with ventilators should take along some reading material and do some self-study both prior to arriving as well as after the shift with the RT. The complete lack of prior basic ventilator knowledge and experience was one of the most poignant lessons learned during this rotation. Special Forces Medical Sergeants need minimum week long class that includes both didactic as well as hands on instruction using different ventilators, both issued and those commonly used in the target region. This would allow us to do better than the 600Vt and 10 breaths per minute the issued SAVENT gives our patients or the potential hours of manual bagging required of a PFC scenario. A schedule that is exclusively SICU shifts, even with the trauma alerts, will preclude the SFMS from gaining experience in the other disciplines he is responsible for. For this reason shifts in other units such as the ED, labor and delivery, neonatal ICU, Neurosurgical ICU, anesthesia and so on, are still recommended with the capstone of the rotation being the SICU shifts at the end of the rotation. This will allow the medic to gain valuable clinical skills in other departments, reorienting himself to proper first world medicine care and simple procedures and bedside manor prior to injecting himself into the world of the SICU. Medicine is a fast paced professional field where many innovations and changes to best practice occur between the medic’s 4 or 5 years away from a hospital. Attached at the end of the paper is a 4 week schedule that may better integrate the medic into the world of the SICU gradually proctored by both nursing and resident staff while not neglecting other crucial skillsets. It is also suggested that the medic have goals for the day’s shift including some recommended reading such as Scott Weingart’s “Dominating the Vent,” when working with the RT or even some of the hospital’s own policies. While rotating in the SICU the opportunity to attend the Air Force Center for the Sustainment of Trauma and Readiness Skills (C-STARS) 5-day Tactical Critical Care Evacuation Team (TCCET) course was presented. The TCCET concept pairs an RN or doctor with an Army dustoff medic in a helicopter either responding and picking up patients from the battlefield or transferring critical patients from intratheater facility to facility via fixed wing platform. There are multiple simulators with life-like mannequins, lights and blaring sound that include ventilators, monitors, pumps and simulated medications that you can actually push. The POI includes a TCCC lecture and practical exercises, cadaver lab great head injury lecture, and multiple scenarios that will challenge any participant no matter the level of education or experience. It also included participation in the live Joint Theater Trauma System (JTTS) conference call from Afghanistan that takes place every Thursday morning at 0800 EST. This was a great opportunity for all of the personnel involved in the treatment of a real world US casualty to explain to the worldwide audience what happened with the patient during the time that they cared for them all the way from the point of injury to arrival at LRMC and beyond. It was believed that all of this could aid in identifying shortfalls in the emerging PFC recommendations during the plane/ helicopter capability phase and the general knowledge of the patient. Having had little or no experience with most of the equipment, there were times when it was easy to get lost in technology as the “patient” crashed mid-flight. As stated in the class, dustoff medics would often push aside the pieces of equipment they were not familiar with in order to maintain homeostasis with what they were comfortable with. Equipment will definitely improve patient outcomes while making the job of the medic easier only if it is accompanied with the proper training and education. After taking some time to learn how to operate the ventilator it improved the capability of the medic allowing him to move on to other emerging life threats with confidence in ventilation. In the future it is highly recommended that SFMSs participate in scenarios either during a TCCET class or outside of one with one of the C-STARS proctors running the scenario. It is not advised that the medic forego an entire week of clinical participation in order to attend this class as many concepts and lectures are already included in the 2 week Special Operations Combat Medical Skills Sustainment Course (SOCMSSC) and the repeat of those basic subjects are not worth missing the few days of clinical experience the medic would miss. If a TCCET class happens to run concurrently with the Rotation it would be possible to add 5 days on in order to attend. This would max out the USASOC allowed 33 days for an MPT rotation. Prior coordination should be made with CSTARS and the contact at the Hospital if interested. Overall this rotation was an amazing opportunity with all levels of staff willing to take the time to teach at the level of the medic and include him in the care of patients through the entire spectrum of care as planned. There were even times when it was hard to decide what to do when presented with concurrent opportunities to participate in procedures or training events. This is a highly recommended rotation for the medic interested in both practice and theory. Attendings that know what the SFMS is capable of will not hesitate to put them on the spot and push the boundaries of both knowledge and skill, perhaps at rounds or in front of an entire Trauma Conference! (Triangle of death, TXA, whole blood transfusion) Nurses will gladly let you do anything you are comfortable in doing, within the boundaries of the scope, once it is shown that there is a desire and competence. Residents may seem standoffish until you integrate yourself into the team and what they are doing over the course of an extremely long shift. Other notes to the medic attending MPT at UC:The Kingsgate Conference Center Marriott will give you the government rate for lodging making it a 7 minute walk to the ED when you are on call. If staying at the Kingsgate, the front desk will give you free daily passes to the UC Rec Center Gym witch is an amazing facility.Arrive your first day in a shirt and tie for badging and tour. After you get scrubs you will change and have your scrub class.Make sure your badge says Paramedic after your name. (You are an ATP) and the bottom part of the badge reads Special Forces Medic. I caught many people reading my badge when they didn’t know who I was and didn’t want to ask. This will make a difference in what you are able to do initially.Learn the GCS score. It is used every day on every patient assessment.If you don’t know that or labs such as ABGs and Chems, either write out cheat sheets or go to the medical book store and get a Maxwell pocket Guide that includes those things and more.Go to the CSTARS Staff and introduce yourself. Ask MAJ Christine Novack about getting access to the Epic electronic medical record system.There is a locker room where you can bring clothes to change out of once you are done for the day. You can pull scrubs to wear from the service window to wear each day. Don’t “forget” to shave here even if the majority of male staff have facial hair. Many of the staff who are key to your rotation are current or former high ranking officers that just don’t appreciate it .If you don’t know a word or acronym take some time to write it down and look it up. Some of the terms include INR, IS, Base Deficit, BUN, Lactate, LTAC, DT etc. Your goal for the rotation should be to respond via the pager to the ED and assist with care and continue to follow the patient through imaging, surgery and ICU. Try and maintain a written log of the vitals and ins and outs like you would with one of your patients. If you don’t have a flowsheet you can download one at austeremedicine. from the downloads page.Attend the resident trauma conference each Thursday at 1200-1300 no matter what else you are doing. Good lectures and discussions and free catered lunch at the Medical Sciences Building room 2351.Learn how the residents present patients to attendings during rounds using the Review of Systems (ROS).Bring Stethescope, Trauma Shears, pen light and hemostat.SFMS Roatation Procedure List (Draft)procedures requested for ERDateDateDateDateDateDateNPA??????OPA??????apply a NRB mask??????apply a Nasal Cannula??????BVM operation ??????suction an airway ??????manage a patient on a ventilator??????Superglotic Airway??????DL Intubation ??????Cricothyroidotomy??????Chest Seal??????Needle Decompression??????Chest Tube ??????Chest Tube management??????Check Pulses??????Apply pressure bandage??????sutures/staples??????wound cleaning??????12 lead ECG??????start an IV??????Draw venous blood sample??????urinary catheterization ??????These procedures are all within the SOCM Paramedic's scope of practice and signed with a MOA on file with the hospital. This does not supersede clinical judgment or Medical Director acceptance of risk. Site Coordinator___________________________________Date___________ ???SFMS Paramedic _ Date__________ ????????10th Special Forces Group University of Cincinnati Medical Center Surgical Intensive Care Unit RotationObjectives:Follow full spectrum of care for trauma and acute surgical patientsParticipate in ICU care of acutely injured and critical ill surgical patientsAssist with monitoring to includeInvasive and non-invasive physiologic monitoringAcquisition and interpretation of labsAssisting (within scope of practice)with respiratory careInterpretation/discussion of Ventilator settings, alarms and waveformsSelection of modes of ventilationABGs and PaCO2 waveformsAssist with endotracheal suctioning, oral care and pneumonia prevention strategiesAssist with sedation/analgesiaDirectly assist with monitoring of pain and sedation levelsIndependent assessment of patient needs to be correlated with mentoring nurse’s assessmentWork directly with mentor, learning pump use, dosing adjustment and selection of agentsMedic will not program pumps or independently administer medicationsAssist with blood transfusionMedic can prime tubing, prepare transfusion and discuss indications with mentor and ordering providersMedic will not independently administer blood productsAssist with all aspects of bedside care including start of shift assessmentsPositioningHygieneNutritionInfection controlFollow patients through entirety of course when feasibleRespond to Trauma STATS when not involved in acute bedside care activitiesAccompanies either new trauma patients (if in SRU on arrival) or assigned SICU patients when those patients go to the OR.Intent is shadowing and observation of both operative and anesthetic considerationsDecision to switch patients (assigned patient A but follows new patient B from SRU to OR and back to SICU) will be made in consultation and with agreement of assigned mentor and SICU charge nurseEducationParticipate or observe rounds in the same pod each dayWhile medical students or residents will present patients on rounds, medic will prepare similarly in order to best benefit.If mentor feels it is in best interest of medic education additional patients may be pre-rounded on within the same podMedic will follow SICU team on rounds through entirety of assigned podIf acute care issues are being addressed with assigned patient during this time then medic should stay at bedsideParticipate in the simulation lab scenariosTo be arranged on a case by case basis with the director or deputy director of CSTARS. Every effort should be made to avoid breaks in patient care in the midst of an assigned shift. AccountabilityShifts will be pre-assigned before rotationMedic will meet with charge nurse before each shift for mentor and patient assignmentIf medic is responding to a trauma alert it is his responsibility to notify the mentor prior to leaving the SICUUpon arrival in the SRU the medic will identify himself to the trauma attendingIf simulation training is arranged during a shift, it is the responsibility of the medic to coordinate with the mentor and to report back with the mentor when done in simulation unless this is after the scheduled end of the shift.These points are not meant to be onerous but simply to assure that UCMC staff have accountability of the medic who is here in a student status. This is both for the educational benefit of the medic and for liability purposes.Michael C. Petro, MDLt Col, USAF, MCDirector, C-STARS CincinnatiTitle: Scope of Practice for ARMY SPECIAL FORCES MEDICEffective Date: 1/25/14Section I - Role and Scope of Practice – Special forces medical sergeantThe role of the Special Forces Medical Sergeant (SFMS/Medic Rotator, also encompassing all military “Medic” job classifications that include advanced trauma and medical care beyond first aid in which expected job duties would include those listed in Section II) is recognized to be a broad and complex field of knowledge and skill encompassing: first aid, life saving trauma care, primary medical care and preventative medicine. The SFMS may be called upon to care for patients in the field and hospital both foreign and domestic. The rotation of the SFMS through University Hospital is designed to support the ongoing education, skill building and reinforcement of prior learning and experience. It is important for the SFMS to realize there is not a specific civilian job classification that they will be working under while in University Hospital. Their oversight and reporting will be primarily at the physician level. Task oversight such as peripheral IV access, urinary catheter insertion, or splinting may be from nurses and technicians in the hospital who are qualified to provide that task oversight. Care and treatment provided by the SFMS along with the outcomes of that care must be documented and reported to the primary care providers. Any complications, errors, or adverse events stemming from the care provided by the SFMS must be reported by the SFMS to the overseeing physician AND the patient’s primary nurse or unit charge nurse.The SFMS will be expected to gain clinical knowledge in the intensive care units, emergency department and operating room at The University Hospital. To optimize the learning experience, the rotator will be allowed to participate in direct patient care/procedures and tasks as directed by the supervisory resident/attending physician and /or assigned nursing preceptor. All hands on opportunities will adhere to the unit protocols and will be determined at the discretion of the supervising personnel based on demonstrated skills level, medical education, scope of practice, and foremost, upon the stability of the patient. Section II - Additional Tasks/ResponsibilitiesThe Special Forces Medical Sergeant (SFMS) will provide, under the guidance and supervision of assigned supervisory resident /staff physician or nurse for the purpose of education and professional growth, routine and emergency care for:Uncomplicated illnesses, injuries or problems that have low risk for the patient;Major illnesses, injuries, conditions or procedures without significant risk to life; Major illnesses, injuries, conditions or procedures that carry substantial threat to life. (Recognizing the educational needs of the resident staff and medical students, attempts will be made to allow the SFMS Medic Rotator the opportunity to perform invasive procedures when available and under the supervisory resident or staff physician present.) The SFMS/Medic Rotator scope of practice includes: Patient assessment.Triage of patients.Disposition of patients.Airway management including uncomplicated, semi-planned intubation. (Typically patients with poor reserve, declining saturations on BVM or of unfavorable body habitus will be deferred to the mid-level resident staff. ) Bag-valve-mask or bag-valve-tube ventilator support.Independently initiate peripheral intravenous vascular access.Central venous lines will generally be obtained by resident or attending physician. (If agreed upon by both the attending and the resident faculty, medics may initiate jugular or femoral access under their direct supervision.)Patient immobilization and transport.Urinary tract catheterization and placement of a nasogastric or orogastric tube for lavage or gavage after consultation.Wound debridement/care, drainage or associated procedures under supervision.Wound suturing.Bandaging, splinting and casting in consultation with covering physician.Emergency needle and tube thoracotomy will be allowed under the supervision and discretion of the supervisory resident or staff physician and with consideration of the education needs of the residents, medical students and patient stability.Hemorrhage control (tourniquets)Assess, order labs/ plain x-rays with consultation of covering physician.Evaluation of urinalysis, blood count, Gram staining, stool O&P, thick/thin blood smears, KOH and saline slide preparations, rapid diagnostic test results from kits such as card, vial or blister-packs and selection of response to serology for communicable diseases and to bacterial and fungal culture results in consultation with covering physician.Collection, preparation, preservation and shipment of specimens for pathology evaluation. Medics will not be allowed to program medication infusion pumps, push medication or directly adjust ventilator settings but will be actively involved in decision regarding these actions. An SFMS who also has and maintains certification as a Nationally Registered Emergency Medical Technician – Paramedic (NREMT-P), and has and maintains Advanced Cardiac Life Support (ACLS) certification may, at the direction of the supervising physician, perform all skills that these certification permit such as medication administration during cardiac arrest and defibrillation.Signatures of Collaborating PartiesThe undersigned have agreed to the terms and conditions of the aforementioned Scope of Practice and the following terms and conditions:Communicates clearly telephone and verbal orders and is consistent with hospital policy.Documents all care and education provided to the patient in the patient medical record.Maintains all aspects of patient confidentiality. Acts in a cost effective manner.This scope of practice contains all necessary provisions required by law. Any changes or amendments herein, must be agreed to by the undersigned, in writing and incorporated as part of the Scope of Practice._______________________________________________________________________________________SFMS/Military MedicDate______________________________________________________________________________________Program ManagerDateUniversity of Cincinnati Special Forces Medic MPT Rotation WishlistSunMondayTuesdayWednesdayThursdayFridaySaturday0900 Badge0700-19000700-19000700-19000700-1900Human ResourcesEmergency Dept NursingEmergency Dept NursingEmergency Dept ResidentEmergency Dept ResidentTravel and check inLunchOrientation1150-13001300 Scrub class &Trauma ConferenceOR orientationMedical Science BldgRoom 23510700-1700?0700-1700?0700-1900?0700-1900?0700-1900?0700-1900?Anesthesia Anesthesia NeuroSurg ICU NursingNeuroSurg ICU ResidentOrthopedic SurgeryOrthopedic SurgeryOFF / Call1150-1300Trauma ConferenceMedical Science BldgRoom 23510700-1700?0700-1700?0700-1700?0700-0700 Friday0700-0700 SundayLabor and DeliveryLabor and DeliveryLabor and DeliveryTrauma Surg Team ResidentTrauma Surg Team ResidentOFF / CallOrientation1150-1300OFF / CallTrauma ConferenceMedical Science BldgRoom 23510650-19000700-19000650-19000650-19000650-1900Surgical ICUSurgical ICUSurgical ICU NursingSurgical ICU NursingSurgical ICU ResidentOFF / CallCharge Nurse OrientRespiratory Therapy1150-1300Check out and TravelShadowTrauma ConferenceMedical Science BldgRoom 2351PFC MPT Schedule Recommendations with Daily Goals and Wish ListDay 1-MonKingsgate Marriott Hotel, Travel and check-in. Find the room where you need to be the next morning.Day 2-TuesProper badge title, Orientation, Scrub class and OR familiarization.Day 3-WedBegin first shift orienting in the ED with the nursing staff. This will allow the Medic to become familiar with hospital procedures and practices while being re-exposed to clinical medicine.Day 4-ThursAnother day working in the ED building confidence in basic medical skills and becoming familiar with staff and layout of hospital including where to find supplies. Break for lunch and attend the Resident Trauma conference.Day 5-FriWork in the ED with a resident physician proctor. This will allow you to continue working in the ED but now discussing and being involved with decisions for care. Remain on call at night as it will get busy.Day 6-SatSame as above with a focus on patient assessments, ultrasound and consulting other services. Even doctors call each other when they what another opinion or advice.Day 7-SunOff/ on call - There are still good traumas that occur being that it is a weekend and people are working around the house with power tools and ladders.Day 8-MonFirst of 2 days working with CRNAs and Anesthesia Residents. You should try and work on pre-surgery airway and medical history assessments as well as managing airways using different techniques. Make it known that you are also trying to get a few intubations.Day 9-TuesSame as above. Note patient positioning and everything else going on in the OR so that you are ready to assist patient prep and possible scrub-in when given the opportunity in the future.Day 10-WedToday should focus on nursing skills in the Neurosurgical ICU. Notice patient positioning, desired core body temperature, calculating ICP and different neuro assessments especially the GCS while intubated and not.Day 11-ThursSecond day in the Neurosurg ICU would be ideally proctored by a resident physician involving the medic in care plans while rounding the unit. Break for lunch and attend the Resident Trauma conference.Day 12-FriBoth Friday and Saturday should be proctored by the on-call senior orthopedic resident who would be responding to pages in the ED. Often times there are cases that arrive in the ED that are clearly ortho-only cases that don’t involve other body systems or require resuscitation and won’t be alerted on the trauma pager. These often involve dislocations and assessments for compartment syndrome. Day 13-SatSame as above but try and get involved in surgical debridement and other procedures. Ortho uses ketamine boluses more than other services for some of these procedures. Note dose amounts and other drugs added while observing nystagmus and patient behavior and compliance.Day 14-SunOff/ on call – Give Ortho residents your pager number so you can now respond to both trauma and ortho pages.Day 15-MonLabor and delivery orientation with nursing staff. Focus on building raport and explaining why you are there and what you are trying to accomplish. Assessments, prenatal care, being prepared for birthing and getting to know the unit. Try and set yourself up for attending and assisting in both vaginal and C-section births. Know how to tell when both the mother and unborn baby are in distress. Day 16-TuesL&D nursing. Have your proctor introduce you to the NICU and new born assessments if possible. Post your pager number in order to respond to afterhours labor.Day 17-WedL&D with a resident physician expanding on the concepts encountered with nursing staff. Continue building rapport and confidence with the L&D staff in order to attend live births.Day 18-ThursThis will be your first of 2 long shifts with a the Senior Trauma Resident. This will begin with rounds discussion promptly at 0730 in the SICU conference room. The medic should note how each patient is discussed with many people involved. A preliminary plan is made for each patient including procedures, meds, nutrition rehab and discharge. After the hours of discussion, rounds will be physically made to each of the patients rooms where the preliminary plan will either be confirmed or changed. After rounds through all of the units the residents will begin doing all of the procedures and putting in orders for meds etc. At any point in the process the Residents may be paged to respond to trauma Alerts and Stats. Figure out what denotes the difference. Day 19-FriRecover from the long shift and if able respond to the Trauma Stat pages at nightDay 20-SatThis will start off the same as the previous Trauma shift only getting busier in the evening with more trauma cases. Day 21-SunRecover from the long shift and if able respond to the Trauma Stat pagesDay 22-MonThis shift should have the medic following the Charge Nurse around the Surgical ICU. Shift will start at 0650 in the SICU will allow the medic to become more familiar with nursing staff and long term patients, layout of the unit and location of supplies. The charge nurse normally attends the initial discussion of trauma patients at rounds and can also respond to trauma stat pages and cover other nurses when needed for breaks or understaffing.Day 23-TuesAfter becoming familiar with the SICU the medic should now be paired with a respiratory tech in a specific pod. This will allow the medic to become more familiar with ventilator settings and adjustments, ABG interpretations, SBTs, as well as more basic procedures such as airway suctioning. Day 24-WedThis will be the first of 3 shifts exclusively working with a single nurse on either one or two patients during the 12 hour shift. Every effort should be made to understand every detail nursing care including handover, assessment, positioning med admin, ulcer prevention and care, tube care etc. Continue responding to pages when possible.Day 25-ThursContinue working with SICU nursing preferably with a patient who had just arrived the night prior in order to identify the priorities of what is required of a multisystem trauma patient. Remember to break for lunch for the Trauma conference. Day 26-FriLast shift in the SICU, this time with the resident physician assigned to a side of the unit. Clear up any questions you have for prolonged patient care.Day 27-SatAt this point the rotation could be considered complete. If other arrangements have been made there still remains the latitude to attend the TCCET course or rotate though other departments while staying under the maximum 33 days of TDY. ................
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