INTENSIVE CARE MEDICINE - egyfellow.mohealth.gov.eg · Intensive Care Medicine Egyptian Fellowship...

INTENSIVE CARE

MEDICINE

Egyptian Fellowship

Intensive Care Medicine Egyptian Fellowship

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Table of Contents Introduction; ..................................................................................................................................... 5

Structure of the training program for the ......................................................................................... 7

Egyptian Fellowship of Intensive care medicine ............................................................................. 7

First two years of training (Y1& Y2) ........................................................................................... 8

Third year of training (Y3, ICT1) ................................................................................................ 8

Fourth and fifth year of training ................................................................................................... 8

(Y4, ICT2 and Y5, ICT3) ............................................................................................................. 8

Regulations of the training program for the ..................................................................................... 9

Egyptian Fellowship of Intensive Care ............................................................................................ 9

Program Intended Learning Outcomes .......................................................................................... 13

Knowledge & Understanding ......................................................................................................... 13

Intensive care procedures ............................................................................................................... 18

Y1 & Y2 ......................................................................................................................................... 20

1-General Medicine (GM) (Internal medicine) .......................................................................... 20

2-Basic sciences ......................................................................................................................... 26

Y3 (ICM1)...................................................................................................................................... 30

1- Basic intensive care medicine ................................................................................................ 30

2-Adult Intensive care medicine ................................................................................................ 40

Y4 &Y5 (ICM3&ICM4) ................................................................................................................ 51

1- Pediatric intensive care medicine .......................................................................................... 51

2-Trauma and burns ................................................................................................................... 53

3- Surgical post operative intensive care ................................................................................... 57

4-Medical intensive care ............................................................................................................ 60

5- Toxicology ............................................................................................................................. 63

Methods of assessments ................................................................................................................. 64

1-Regulations ............................................................................................................................. 64

2-Structure of the examination 64


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Introduction The goal of the Fellowship in intensive care medicine ICM is to provide trainees with background

knowledge necessary for the care of critically ill patients and an appreciation of management

issues unique to this patient population.

Intensive care medicine is a multidisciplinary field concerned with patients who have sustained, or

are at risk of sustaining, life threatening, single or multiple organ system failure due to disease or

injury. Intensive care medicine seeks to provide for the needs of these patients through immediate

and continuous observation and intervention so as to restore health and prevent complications.

A Fellow will become competent in all aspects of recognizing and managing acutely ill adult

patients with single or multiple organ system failure requiring ongoing monitoring and support.

Dedicated faculty provides a comprehensive, state of the art approach to patient care in a complex

environment. The breadth of clinical experiences in this multidisciplinary fellow training program

provides equal learning opportunities for critical care fellows.

The educational program for this fellowship will include lectures, clinical cases, procedures,

skills, and other scientific activities


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Structure of the training program for the

Egyptian Fellowship of Intensive care medicine The Egyptian Fellowship Board is a 5 years supervised on job training program that includes 2

year of structured general medicine training, followed by 3 years of Intensive Care Training (ICT).

Both general medicine and ICT must be conducted in accredited hospitals before sitting for the

final examination. A list of hospitals will be accredited yearly by the scientific council.

FIRST TWO YEARS OF TRAINING (Y1& Y2)

The trainees will spend these two years in a rotation program as it appears below in the table to

cover all the related subspecialties. These 2 years should be spent in certain accredited hospitals

After spending 18 months of these two years of training, the trainees are legible to site for the 1st

part exam of the Egyptian Fellowship of Intensive Care Medicine.

Important Notice: Trainees must pass successfully all the foundation courses (evidence based

medicine, communication skills, research methodology and medical ethics) before being

promoted to Y3 (CCT1) of their training. Full information about foundation courses is

available at the Egyptian Fellowship website and administration office.

THIRD YEAR OF TRAINING (Y3, ICT1)

The trainees will spend this year in Intensive Care practice basics in accredited training hospitals.

FOURTH AND FIFTH YEAR OF TRAINING (Y4, ICT2 AND Y5, ICT3)

The trainees will spend these two years in accredited hospitals where they will have rotations in

coronary care units, neurology ICU units, cardiothoracic surgical ICU units, nephrology dialysis

units, liver transplantation and renal transplantation units , Pulmonology units, neurosurgery post

operative care units, general postoperative care units, pediatric ICU, and intensive care units as it

appears in the table below

By the end of the 5th year, trainees will be legible to site for the 2nd part and 3rd part exams of the

Egyptian Fellowship of Intensive Care.

The following table illustrates the job rotational plan for the Intensive Care Fellowship over the

five year training program;

Internal medicine Y1& Y2 Training duration

Months

Diabetes & metabolism

Endocrinal

Rheumatology

3

Year Training

Y1& Y2 (GM) General Medicine

Y3 (ICT1) Intensive Care Training 1




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Hepatology 2

Hematology 2

Nephrology 2

Cardiology 3

Pulmonology 3

Emergency 3

Gastroenterology 2

Neurology 2

Infectious disease 2

In case of unavailability of the above mentioned subspecialties or any of them, the rotation will be

spent in the general internal medicine with selection of the intended cases

Y3 (ICT1) Training duration

Months

Basic Intensive Care training 12 months

Y4 (ICT2) - Y5 (ICT3) Training duration

Months

Coronary care units 3months

Cardiothoracic surgical ICU units 2 months

Pulmonology ICU 2 months

Nephrology dialysis units 1 month

Transplant units

liver transplantation ICU

Renal transplant ICU

2month

Pediatric ICU 2months

Neurology ICU units 2 months

Neurosurgery post operative ICU 2months

General emergency post operative ICU 2months

Intensive care units 6 months

Regulations of the training program for the

Egyptian Fellowship of Intensive Care

Entry requirements

Graduation from medical school and successful completion of the pre-registration

house officers’ year.


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Trainees who are enrolled in the Ministry of Health and Population (MOHP) residency

program as Intensive Care trainees: will start the program from Y1.

Trainees who have had their masters’ degree in general medicine, cardiology,

pulmonology, anesthesia or ICU: will join the program from Y3 (CCT1). These

trainees will be exempted from Y1& Y2 and the 1st part exam of the Egyptian

Fellowship of Intensive Care.

General Rules and Regulations

Trainees should pass a local TOEFL exam with a minimum score of 500 and should

pass a computer course in word processing, Internet and power point in order to be

eligible for the 1st part exam

Trainees should pass successfully the 1st part exam of the Egyptian Fellowship of

Intensive Care before being promoted to Y3 (ICT1) (including exam of basic science)

Trainees must pass successfully all the obligatory foundation courses (evidence based

medicine, communication skills, research methodology and medical ethics) before

being promoted to Y3 (ICT1) of their training. Full information about foundation

courses is available at the EF website and administration office.

After completing the whole training period, completing all logbook requirements and

completing their research project, trainees are allowed to sit for the 2nd part exam.

Only candidates who pass successfully the 2nd part exam are allowed to sit for the 3rd

part.

Trainees’ General Duties and Obligations during the

Training Period of the Intensive Care Fellowship Program

Trainees must attend at least 75% of the lectures designed for each module.

Trainees must attend at least 75% of the practical sessions designed for certain

modules.

All trainees will work as trainees (dedicated full time) in the accredited hospital and

they must fulfill all trainees’ jobs defined by supervisors and trainers.

The trainees should be responsible under supervision for inpatient routine work

The trainees should be actively involved and fully responsible for patient care

including sharing in making decisions about diagnosis and management under

supervision of consultants.

They must take supervised shifts (on call duties) according to hospital requirements

and regulation.

Trainees’ Specific Duties and Obligations during GM

During their rotations in General Medicine, trainees will act as junior trainees and will share the

same responsibilities of corresponding trainees in these specialties. These include full obligations

towards admitted patients, in the inpatient and outpatient clinics, mandatory clinical and academic

activities and record these activities as required in the log book.

Trainees’ Specific Duties and Obligations during ICT


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Obligations in the Intensive Care units The trainees should attend the Intensive Care rounds and become actively involved in

history taking, examination and management of these critically ill patients under

supervision from their trainers.

The trainees should also perform regularly under supervision certain diagnostic and

therapeutic procedures.

The trainees in the Intensive Care rotations will be responsible for supervised admission of

patients. In such cases, the trainees will write the admission form for the patient with a

written plan of management after consultation and approval from consultants or

supervisors.

During their Intensive Care rotations, trainees should attend and participate in at least 75%

of the total number of clinical rounds and journal club meetings within the rotation period.

Obligations towards admitted patients

The trainees in the inpatient rotations will be responsible for reporting the progress of the

patient in stuff rounds.

The trainees will be responsible for the following:

Completing history and examination forms.

Writing investigations requests and ordering necessary diagnostic procedure.

Writing medication sheet according to the management plan approved by the

supervisors.

Writing daily progress notes.

Reporting results of investigations.

Discussing the case in weekly inpatient rounds with consultants and supervisors.

Writing discharge summaries and follow up cards

Writing sick leaves and medical reports for inpatients

Logbook The trainees must keep and update the Logbook where they record all activities and skills

performed and learned during the training program whether being performed independently or as

assistant or observer. Each activity registered in the Logbook should be countersigned by the

trainer and finally by the educational supervisor. The trainer and educational supervisor shall sign

the completed logbook at the end of the training program.

Research project The trainees should undertake one research project during their training program under guidance

and supervision of their trainers. After passing the 1st part exam of the Egyptian Fellowship of

Intensive Care, each candidate will be given a topic chosen by the scientific council. The review

article should be presented to an educational committee before the trainee is accepted for

admission to the 2nd

part exam of the Egyptian Fellowship of Intensive Care

Evaluation Procedures 1st, 2nd and 3rd parts of the Intensive Care Fellowship Exam.

Performance of the trainees will be evaluated on regular and continuous basis and the evaluation

process should involve all aspects of the training including theoretical, clinical, investigative

procedures, skills as well as attendance and participation.

The trainers who are required to write confidential reports of the performance of each trainee

should evaluate the trainee periodically. The trainee should not be allowed to proceed in the

training program and move to the next rotation unless he/she attains a satisfactory level of


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performance acceptable to the responsible trainer and educational supervisor.

Holidays According to the Ministry of Health regulations

Interruption of Training It is not permissible to interrupt such a structured training program except in major unavoidable

circumstances. Such circumstances should be convincing and approved by the Secretary General.

The interruption once approved should not be for more than one year. Interruption of the training

program for more than one year shall result in dismissal from the program and cancellation of the

preceding training period

Rational Statement The purpose of this curriculum is to describe the knowledge, skills and attitudes that must be

gained by trainees in Intensive Care in order to practice independently and safely. The curriculum

also describes teaching, learning and assessment methods that will be used to ensure that the

trainees have attained the required competencies. We derived the content of the curriculum

through consultation and revision of the European and the American Board curricula.. Therefore,

we ensured that the curriculum is up to the international accepted standards of practice in Intensive

Care training. In the meantime the curriculum addresses national needs for Intensive Care practice

and the availability of training resources

Aims

The aim of the program is to provide the community with skilled independent intensivist

who:

1. Have essential knowledge about the pathophysiology, clinical presentation and

management of critical illnesses.

2. Have skills necessary to diagnose and manage common and important life threatening

emergencies.

3. Have achieved certain level of competency in Intensive Care procedures and management

of specific Intensive Care subspecialties including cardiac, organ transplant and

neurological cases.

4. Have communication skills that result in effective information exchange and teaming with

patients, their families, and professional associates.

5. Are capable of applying national and international standards of patient care using the

principles of evidence based medicine competently in practice.

6. Keep ethical attitudes and respond to the changing health needs of the community.

7. Keep their medical standards through encouraging the concept of continuing medical

education.


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Program Intended Learning Outcomes

Knowledge & Understanding

By the end of the program, Intensive Care fellowship trainees will gain knowledge and

systematic understanding of:

1. The basic scientific knowledge related to critical illness in its different aspects.

2. The etiology, clinical features, natural history and prognosis of critical illness in different age

groups

3. The basic concepts of important diagnostic and therapeutic procedures, their indications,

limitations and complications.

4. The management of certain subdivisions in critical illness including cardiac, neurological and

transplanted patients.

5. The differential diagnosis of various critical illness presentations.

6. The principles of health education, disease prevention, amelioration of suffering and disability

and rehabilitation where relevant.

Skills

I. Intellectual skills:

By the end of the training years, trainees will be able to:

1. Interpret, integrate and document the history and physical examination findings with

histopathology to arrive to an appropriate provisional diagnosis and differential diagnosis.

2. Select the most appropriate and cost effective investigations and diagnostic procedure and

interpret the results of investigations.

3. Combine the clinical and investigational knowledge, with evidence-based knowledge to reach

proficiency in clinical problem solving.

4. Plan management and design rational therapeutic strategies with the appropriate involvement of

the patient and family.

5. Recognize when a clinical problem exceeds their capacity to deal with it safely and efficiently

and when to request support and expert advice from colleagues and seniors.

6. Make decisions in different aspects of delivering intensive care.

7. Interpret and criticize medical evidence logically and scientifically.

8. Analyze common clinical practice, management, and education roles used by intensivist.

9. Corroborate the advances in knowledge which will occur in his work over his entire career.

II. Professional and Practical skills


1. Take a tactful, accurate, organized and problem-focused medical history and relate this to the


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general medical condition of the patient.

2. Perform a reliable focused and appropriate examination in addition to relevant general physical

examination.

3. Choose from the repertoire of clinical skills, those which are appropriate and practical in a given

situation.

4. Competently carry out different therapeutic modalities as detailed in their specific modules.

5. Recognize patients with serious/life-threatening conditions requiring Intensive Care and outline

an initial course of management.

6. Apply sterile, safe techniques and infection control guidelines according to international

principles.

7. Monitor the efficacy of therapy by assessing the patient's response according to the relevant

clinical and investigative parameters and re-evaluate management plan accordingly.

8. Communicate opinion in oral and written form.

III. Skills related to health promotion and disease prevention:


1. Provide health promotion and quality of life advices for patients with critical illness

2. Provide health education sessions for the prevention and management of infectious problems in

the ICU

IV. Skills related to delivery of quality health care services


1. Practice cost effective health care through proper resource allocation that does not compromise

quality of care.

2. Work with health care managers and health care providers to assess, coordinate, and improve

patient care.

3. Acknowledge medical errors and help in the development of systems to prevent them.

V. Generic and Transferable skills:


1-Communicate effectively with patients, in the form of:

Demonstrate respect to all patients irrespective of their socio-cultural or religious status.

Conduct patient interview with patience, attentive listening and respect.

Adequately and clearly explain to the patient and/or his relatives the nature of the illness,

diagnostic and therapeutic plans, possible complications and outcomes.

Provide information in a manner which ensures that patients and families are adequately

informed when being advised of their diagnosis and/or consenting to any procedures or

treatment.

Handle appropriately difficult situations such as conveying bad news or dealing with

patients' anger.

Discuss the progression of the patient's condition, therapeutic outcomes and professional


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mistakes (if any), openly in a way that promotes patient trust and confidence.

2-Communicate effectively with health care providers, in the form of:

Willingness to work effectively and respect contribution in a team with other colleagues,

seniors, coworkers and other health care providers, and to behave honorably towards them

and to acknowledge and respect their opinions.

Seeking formal and informal consultations from colleagues.

Document correct patient’s medical records (admission sheet, progress notes, discharge

sheet, consultation request, investigations, informed consent and drug prescription).

Mange time effectively.

Analyze his own practical experience to recognize his/her strengths, deficiencies, and

limits in knowledge and expertise.

Use evaluations of performance provided by peers, patients, superiors, and subordinates to

improve practice.

Use information technology to optimize patient care and enhance his/her lifelong learning

skills.

Locate, appraise, and summarize evidence from scientific studies related to health

problems of his patients.

PROFESSIONALISM:

1. Accept responsibility for patient care including those who are not able to pay or from different

social or religious background

2. Demonstrate integrity, honesty, compassion, and empathy in his role as a physician

3. Respect the patient’s privacy and autonomy and maintaining appropriate professional

boundaries

4. Demonstrate accountability and commitment


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The core curriculum for training in adult ICM is categorized in domains, each of

which is presented as Knowledge, Skills, Attitudes and behavior, lectures,

procedures, workshops, and different scientific activities targeting competence and

professionalism, in addition to basic sciences.

The curriculum refers only to adult practice except for those items listed in the

pediatric section.

Syllabus


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Intensive care procedures

GENERAL DESCRIPTION of the training including educational purpose, rationale or value:

The training program requires certification of clinical competency in specified diagnostic and

therapeutic procedures.

Trainees receive both didactic and various practice sessions, life videos, and simulator training in

all procedures prior to performing them on patients, as an observer, then active participant, and

finally independent operator. All trainees must be supervised by a certified trainee and document

the procedure in their procedure logbook.

TRAINEE RESPONSIBILITIES:

The trainee is responsible for attending the designated lectures to learn specific

Techniques and demonstrate initiative in completing the requisite number of procedures.

EDUCATIONAL OBJECTIVES:

During this training, the trainee will:

1. List the indications, methods, alternatives and complications for each procedure.

2. Discuss the principles of informed consent and ensure that this is obtained on all

Patients.

3. Become certified in all required procedures prior to completing the training program.

4. Be supervised by a certified individual for procedures until he/she is certified.

5. Document all completed procedure in the Procedure Log Book.

6. Discuss results of bodily fluids obtained, e.g., ascites, pleural fluid, & synovial

fluid.

7. Document procedure in the patient’s record clearly and appropriately

THE SPECIFIC PROCEDURES REQUIRED for determination of clinical competency are:

1- Tracheal intubation 11- Lumbar puncture

2- Tracheotomy 12- NG tube placement

3- Intercostal intubation 13- Cardiac pacing

4- Thoracocentesis 14- Pericardiocentesis

5- Abdominal lavage 15- Cardio version

6- Cut down 16- Urinary catheterization

7- Abdominal paracentesis 17- FAST

8- Arterial line placement

9- Arterial puncture for ABG

10- Central line placement

a- Internal jugular

b- Subclavian

c- Femoral

These procedures will be implemented over the five years training program in a synchronized way

with the nature and type of the educational program for each year.

Year 1 &2 will get the following training procedures competency

1. Thoracocentesis


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2. Pericardiocentesis

3. Abdominocentesis

4. Urinary catheterization

5. NG tube placement

6. Arterial puncture for ABG

Year 3 will get the following training procedures competency

1. Tracheal intubation

2. Tracheotomy

3. Intercostal intubation

4. Central line placement

a. Internal jugular

b. Subclavian

c. Femoral

5. Lumbar puncture

6. Arterial line placement

7. Cut down

8. Cardio version

Year 4 and 5 will get the following training procedures competency

1. Abdominal lavage

2. FAST

3. Cardiac pacing


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Y1 & Y2 1- General Medicine (GM)

(Internal medicine)

The following part of the curriculum describes the requested learning outcomes, topics and clinical

conditions that the candidate must achieve study or encounter during the whole internal medicine

program. The candidate should master management of chronic illness through rotation training

program in different medical subspecialties. This will prepare the candidate to face in the

following training years, patients with acute exacerbation of chronic illness or acute illness in a

chronically ill patient. So it is mandatory for the candidate to master and be competent in internal

medicine subspecialties before going through intensive care subspecialty

INTENDED LEARNING OUTCOMES

General internal medicine trainees must achieve the following intended learning

outcomes for the subsequently mentioned clinical conditions.

1. Define the etiology & describe the epidemiology & pathophysiology of the condition.

2. Recognize various clinical presentations through adequate history & full clinical

examination.

3. Have high index of suspicion & screen for important preventable or controllable

medical conditions like diabetes mellitus.

4. Order appropriate investigations to confirm the diagnosis & establish a differential

diagnosis.

5. Write & apply a comprehensive management plan based on patient's risk, & associated

co morbidities. The plan should include:

a. Initial & ongoing medical treatment.

b. Counseling & life style change.

c. Treatment of disease complications if present.

d. Prevention of specific risk (if relevant to the condition).

e. Referral for surgical or other specialty care if indicated.

f. Follow up options & settings.

6. Communicate appropriately with different subspecialties & refer for colleagues

& senior opinion in indicated cases.

THEORETICAL TOPICS

By the end of these two years, Intensive Care fellowship trainees will gain knowledge and

systematic understanding of the following:


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Cardiovascular system (problems & diseases)

1. Coronary artery diseases.

2. Congestive heart failure.

3. Rheumatic heart diseases & rheumatic activity.

4. Infective endocarditic.

5. Cardiomyopathies.

6. Hypertension.

7. Arrhythmias & dysrhythmias.

8. Aortic dissection.

9. Syncope.

10. Dyslipidemia.

Respiratory system (problems & diseases) 1. Bronchial asthma

2. Chronic obstructive airway disease

3. Upper & lower respiratory tract infections

4. Obstructive sleep apnea

5. Suppurative lung disease & bronchiectasis

6. Pleural effusion

7. Pneumothorax

8. Interstitial lung disease

9. Mediastinal syndrome

10. Tumors of the lung & pleura

11. Pulmonary embolism & DVT

12. Pulmonary hypertension

13. Respiratory failure and mechanical ventilation

Infections (problems & diseases) 1. Fever of unknown origin

2. Sepsis, shock ,DIC,ARDS

3. Community acquired infections

4. CNS infections

5. Travelers fever

6. HIV & AIDS

7. Infections in immune-compromised host

8. Tuberculosis

9. Salmonellosis

10. Hepatitis

11. Brucellosis

12. Common genitor-urinary infections

Nutritional problems 1. Cachexia

2. Metabolic syndrome

3. Obesity

4. Osteoporosis

5. Vitamin deficiency

6. Enteral & Parenteral nutrition.

Gastroenterology (problems & conditions)


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1. Peptic Ulceration & Gastritis.

2. GI malignancy (esophagus, gastric, hepatic, pancreatic, & colonic).

3. Inflammatory bowel disease.

4. Gastrointestinal bleeding.

5. Functional disease: irritable bowel syndrome, non-ulcer dyspepsia.

6. Celiac disease.

7. Acute liver injury: jaundice, ascites, encephalopathy.

8. Liver cirrhosis.

9. Gastro-esophageal reflux disease.

10. Gallstones.

11. Autoimmune liver disease.

Neurology (problems & conditions)

1. Transient ischemic attacks.

2. Hemiplegia.

3. Paraplegia.

4. Cranial nerve palsy.

5. Ataxias.

6. Extra pyramidal syndromes.

7. Peripheral neuropathies.

8. Myopathies & other muscle diseases.

9. Myasthenia gravis.

10. Degenerative brain diseases.

11. Brain tumors.

12. Migraine & other headaches.

13. CNS infections.

14. Language problems.

15. Multiple sclerosis.

16. Seizures.

Hematology (problems & conditions)

1. Bone marrow failure & myelodysplastic syndromes.

2. Bleeding disorders (hemophilia & purpura).

3. Thrombophilias (acquired & congenital).

4. Transfusion reactions.

5. Anemia & Haemolytica disease.

6. Leukemia.

7. Lymphoma.

8. Myeloma.

9. Myeloproliferative disease.

10. Amyloid diseases.

11. Care of Bone Marrow Transplantation recipient.

Rheumatology & musculoskeletal conditions

1. Gout

2. Systemic lupus erythematosus & other vasculitides.

3. Rheumatoid arthritis.

4. Osteoarthritis.

5. Tendinitis.

6. Fasciitis & myositis.


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7. Dermatomyositis.

8. Osteomalacia & osteoporosis.

9. Chronic fatigue syndrome.

10. Polymyalgia & temporal arteritis.

11. Septic arthritis.

Endocrine & metabolic conditions

Diabetes Problems 1. Diabetes and Diabetic ketoacidosis.

2. Non-acidotic hyperosmolar coma.

3. Uncontrolled diabetes (type 1 & type 2).

4. Hypoglycemia.

5. Peri-operative diabetes care.

6. Gestational diabetes.

Other Endocrine Problems

1. Hyper/Hypocalcaemia.

2. Adrenocortical insufficiency.

3. Hyper/Hyponatremia.

4. Thyroid dysfunction.

Renal problems & conditions

1. Acute renal failure

2. Chronic renal failure.

3. Glomerulonephritis and acute nephritic syndrome.

4. Nephrotic syndrome.

5. Urinary tract infection.

6. Renal calculi.

7. End stage renal disease.

8. Care of patients on renal replacement therapy.

9. Electrolyte imbalance in renal patients.

Dermatological problems in medical practice

The trainee is requested to recognize the condition, initiate management & timely involve

dermatology specialists

1. Hyperpigmented lesions.

2. Cellulitis.

3. Diabetic ulcers.

4. Erythematous skin lesions.

5. Cutaneous drug eruptions, urticaria & angioedema.

6. Eczema.

7. Vasculitis.

8. Psoriasis.

9. Vitiligo.

10. Herpes zoster & herpes simplex.

11. Lymphedema.

Occupational diseases

The trainee is requested to screen for or suspect the following conditions during routine practice

settings & timely refer to appropriate specialty

1. Lead poisoning.

2. Asbestosis.


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3. Occupational lung diseases.

Traveler’s diseases

The trainee is requested to suspect & initiate investigations and treatment for the

following conditions in high-risk groups.

1. Malaria.

2. Avian flu.

3. Swine flu

4. SARS

Genetic disorder

For The following genetic conditions, the trainee would be able to diagnose the case and

consult appropriately.

1. Down’s syndrome.

2. Turner’s syndrome.

3. Huntington’s disease.

4. Hemochromatosis.

5. Marfan’s syndrome.

6. Klinefelter’s syndrome.

7. Familial cancer syndromes.

8. Familial cardiovascular disorders.

CLINICAL CASES

By the end of these two years, trainees will be able to manage competently the following cases:

Cardiac Cases 1. Acute coronary syndrome

2. Cardiac arrest

3. Syncope

4. Right sided heart failure

5. Left sided heart failure (rheumatic, ischemic, cardiomyopathic)

6. Cardiogenic shock

7. Atrial arrhythmia

8. Ventricular arrhythmia

9. Pericarditis

10. Artificial valve dysfunction

Hypertension

Respiratory Cases 1. Adult respiratory distress syndrome (ARDS)

2. Respiratory failure (COPD)

3. Respiratory failure (status asthmaticus)

4. Respiratory failure (pneumonia)

5. Severe community acquired pneumonia (CAP)

6. Ventilator associated pneumonia (VAP)

7. Aspiration pneumonia

8. Pulmonary embolism

9. Pneumothorax


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10. Respiratory failure in special situations ( e.g. pregnancy)

11. Hemoptysis

Hematological cases 1. Leukemia

2. Lymphoma

3. Coagulation disorders

4. TTP

ITP

Nephrology cases 1. Nephrotic syndrome

2. Acute nephritis


4. Chronic renal failure

5. Hypertension

6. Urinary tract infection

7. Tubular disorders

8. Hematuria for differential diagnosis

9. Proteinuria for differential diagnosis

Endocrinal disorders 1. Thyroid diseases

2. Suprarenal diseases

3. Pituitary diseases

Neurological and neuromuscular cases 1. Epilepsy

2. Cerebro vascular stroke

3. Spinal cord injuries (traumatic, vascular…)

4. Guillain Barré syndrome

5. Myasthenia gravis

6. coma

7. Vegetative state

8. Myopathy

9. Neuropathy

Rheumatology cases 1. SLE

2. Rheumatoid arthritis

3. Vasculitis

4. Connective tissue diseases

Diabetes & metabolism Cases 1. Diabetic cases

2. Electrolyte disturbances

Internal medicine emergency Cases 1. CNS

2. Cardiac

3. Respiratory

4. Abdominal

5. Hepatic

6. Renal

7. Vascular

8. Hematological


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9. Mixed

Gastroenterology Cases 1. Crohns disease

2. Ulcerative colitis

3. Hematemesis

4. Melena

5. Pancreatic diseases

Hepatology Cases 1. Hepatitis

2. HCC

3. Ascites

4. Liver cell failure, hepatic coma

5. Portal hypertension and GIT bleeding

6. Jaundice

Dermatological problems in medical practice 1. Hyperpigmented lesions.

2. Cellulitis.

3. Diabetic ulcers.

4. Erythematous skin lesions.

5. Cutaneous drug eruptions, urticaria & angioedema.

6. Eczema.

7. Vasculitis.

8. Psoriasis.

9. Vitiligo.

10. Herpes zoster & herpes simplex.

11. Lymphedema.

Infectious cases

1. Malaria.

2. Avian flu.

3. Swine flu

4. SARS

5. Meningitis

6. Encephalitis

7. Tetanus

PROCEDURES AND SKILLS

Upon completion of this Y1& Y2 the candidate should be able to discuss the indications

contraindications and complications of every procedure. He should be able to discuss the risk

benefit of each procedure. He should be able to master all these procedures with high competency.

These procedures are;

1. Arterial puncture for ABG

2. Thoracocentesis

3. Abdominocentesis

4. Pericardiocentesis

5. NGT settlement

6. Urethral catheter settlement


26

WORKSHOPS (All to be attended through this Y1&Y2 training program)

1. AIRWAY

2. BLS

3. ACLS

4. ECG

5. LAB.INTERPRETATION

6. ECHOCARIOGRAM TRANSTHORACIC

Y1 &Y2 2- Basic sciences

1. Physiology

2. Pathology

3. Pharmacology

4. Clinical pathology

5. Radiology

6. Immunology & bacteriology


Knowledge : By the end of the first two years of training, trainees should have adequate knowledge about:

The normal function of the human body (cell tissues and organs).

The nature of agents and mechanisms that produce alterations in Structure and function of

the body.

The nature and course of alterations in function produced by Etiological agents and

mechanisms (Pathophysiology) of the body.

The nature and course of alterations in structure produced by Ttiological agents and

mechanisms (Pathological Anatomy) of the body.

The appropriate use of laboratory techniques in identifying diseases or health problems.

The action, metabolism, and toxic effects of drugs.

The therapeutic use of drugs.

The principles and concepts underlying normal behavior and mental illness.

The definition ,classifications, and types of immunological reactions

Bacterial classifications, normal flora, pathogenesis of infection, lab. diagnosis, and best to

treat

Skills: The ability to perform a satisfactory physical exam.

The ability to take a satisfactory medical history including psychosocial, nutritional,

occupational and sexual dimensions.

The ability to utilize data from the history, physical exam and laboratory

evaluations to identify the health problem.

The ability to formulate an appropriate differential diagnosis.


27

The ability to formulate effective management plans (diagnostic, treatment, and

prevention strategies) for diseases and other health problems.

The ability to monitor the course of illnesses and to appropriately revise the

management plan.

The ability to perform routine technical procedures specific to the medical

specialty.

The ability to document the clinical encounter.

The ability to apply the therapeutic use of drugs in patient care.

The ability to recognize the relationship between health and illness, the patient and

the patient's environment.

The ability to apply preventive and health maintenance principles and techniques in

the delivery of health care.

The ability to apply the appropriate use of laboratory methods in identifying

diseases or health problems.

The ability to recognize patients with immediately life threatening conditions.

The ability to manage pain and ameliorate the suffering of patients.

The ability to apply Evidence Based Medicine principles to clinical decision

making.

The ability to Produce radiologic comments that are accurate, concise, and

grammatically correct

The ability to diagnose immunological diseases

The ability to tackle infection through diagnose, management, and prevention

Attitude and behavior: The ability to apply humanistic values in the delivery of health care.

The ability to work cooperatively with other health care workers in the delivery of

health care.

The ability to respect the patients’ dignity, privacy, and confidentiality in the

delivery of health care.

The ability to effectively interact with patients, peers and other healthcare workers

from diverse cultural backgrounds.

THEORETICAL TOPICS RELEVANT TO BASIC SCIENCES

By the end of these two years, Intensive Care fellowship trainees will gain knowledge and

systematic understanding of the following:

Physiology 1. Mechanics of the heart

2. Blood pressure regulation

3. Blood volume regulation

4. Systemic versus pulmonary circulation

5. Coronary and cerebral circulation

6. Renal perfusion and function


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7. Oxygen cascades

8. Lung mechanics

9. Body temperature regulation

10. Hemostasis

11. Body response to trauma

Pathology

1. Inflammation and sepsis

2. Cell injury

3. Cell adaptation

4. Acute respiratory distress syndrome(ARDS)

5. Bronchial asthma

6. Renal failure acute and chronic

7. Vasculitis

8. Basic immunologic reactions

9. Pancreatitis

10. Liver failure

11. Rejection reactions

Pharmacology 1. Pharmacodynamics and kinetics

2. Volume of distribution

3. Vasoactive drugs

4. Antihypertensive drugs

5. Antiarrhythmic drugs

6. Anticoagulants

7. Fibrinolytics

8. Sedatives

9. Muscle relaxants

10. Hypnotics

11. Anticonvulsants

12. IHD drugs

13. Bronchodilator drugs

Clinical pathology 1. CBC interpretation

2. Urinalysis

3. Exudates versus transudates

4. Cardiac enzymes

5. Lipids and lipid profile

6. Tumor markers

7. Coagulopathy

8. Atherothrombotic

9. Ascitic fluid

10. Pleural fluid

11. Broncho-alveolar lavage

Radiology

1. Chest X ray

2. CT chest

3. CT brain


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4. MRI brain

5. CT spine

6. MRI spine

7. Ultra sound abdomen

Immunology & bacteriology 1. Immunology

a. Definitions

b. Classifications

c. Types of reactions

d. AIDS

2. Bacteriology

a) Classifications

b) Normal flora

c) Pathogenesis of infections

d) Lab. diagnosis

e) Bacterial resistance


30

Y3 (ICM1)

1- Basic intensive care medicine

By the end of this year, Intensive Care fellowship trainees will gain knowledge and systematic

understanding of the following items:

1. Criteria for admission and discharge to ICU

2. Oxygen cascades

3. Carbon dioxide cascades

4. Acid base disturbances

5. Transport of critically ill patients

6. Pre and post operative care

7. Comfort care

8. Sepsis and infection control

9. End of life care

CRITERIA FOR ADMISSION AND DISCHARGE TO ICU

Candidates should be able to:

Select patients who are likely to benefit from ICU care

Utilize prioritization, diagnosis, and objective parameters models.

Prioritization Model Candidate should be able to utilize prioritization system for admission of patients

This system defines those that will benefit most from the ICU (Priority 1) to those that will not

benefit at from ICU admission.

Priority 1: These are critically ill, unstable patients in need of intensive treatment and monitoring

that cannot be provided outside of the ICU.

Priority 2: These patients requirpe intensive monitoring and may potentially need immediate

intervention. No therapeutic limits are generally stipulated for these patients.

Priority 3: These unstable patients are critically ill but have a reduced likelihood of recovery

because of underlying disease or nature of their acute illness.

Priority 4: These are patients who are generally not appropriate for ICU admission. Admission of

these patients should be on an individual basis, under unusual circumstances and at the discretion

of the ICU Director

Diagnosis Model Candidate should be able to define and diagnose the life threatening cases from, cardiovascular

system, pulmonary system, neurological system, drug ingestion and drug over dose,

gastrointestinal system, endocrinal system, surgical problems, and mixed cases


31

Objective Parameters Model Candidate should be able to build up the criteria for admission on specific vital signs, laboratory

data, radiological data, and ECG data.

Discharge Criteria The status of patients admitted to an ICU should be revised continuously to identify patients who

may no longer need ICU care.

A. When a patient's physiologic status has stabilized and the need for ICU monitoring and care is

no longer necessary

B. When a patient's physiological status has deteriorated and active interventions are no longer

planned, discharge to a lower level of care is appropriate

Skills Good assessment of critically ill patient

Prioritization

Admission and discharge according to prescribed guidelines

Attitude Communicate effectively with intended medical staff and patient family

Good explanation for either admission or discharge

Oxygen cascades

Knowledge

Trainees should have adequate knowledge and deep understanding of:

Pressure oxygen in air, alveoli, arterial and venous blood, and at mitochondrial level

Oxygen dissociation curve and factors affecting it

Oxygen delivery, extraction and extraction fraction ratio

Hypoxia, causes, and pathogenesis and its management

Oxygen supply, indications, contraindications, and different ways of its supply

Central oxygen and peripheral oxygen stores

Apnea ventilation and how to utilize it

Oxygen behavior at alveoli and tissue

Skills Trainees will be able to:

Calculate oxygen pressure in alveoli

Recognize Alveoarterial gradient, its values, and its importance

Calculate oxygen delivery, and extraction fraction

Read oxygen in ABG

Utilize oxygen dissociation curve for patient diagnosis and management

Improve patient oxygenation through face mask or ventilation

Use appropriately pulse oximeter, and blood gases machine

Attitude


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Be determined to provide the best care possible to all admitted case and based on

appropriate guidelines

Follow-up patients through good and competent monitoring.

Has good communication and relationships with ward staff.

Good handling and utilization of ICU machines

Carbon dioxide cascades

Knowledge Trainees should have adequate knowledge and deep understanding of:

The pressure of carbon dioxide in air, alveoli, arterial and venous blood, and at cellular

level

The hypo and hypercarbia, causes, and pathogenesis and its management

Ventilatory support, indications, and management

The central and peripheral carbon dioxide stores

Apnea ventilation and how to utilize it

The use of capnogram


Use capnogram appropriately for the diagnosis management and outcome detection of

their patients

Adjust carbon dioxide in a ventilated patient

Read carbon dioxide in ABG

Operate appropriately capnogram, and blood gases machine

Knowledge Trainees should be able to:

Define anion gab, its value normal or abnormal and discuss how to use it in diagnosis

and management

Define the normal value of ABG and recall the definition of each item

Discuss the classifications causes, diagnose, and management of acidosis

Discuss the classification, causes, diagnosis, and management of alkalosis

Discuss pH and Henderson Hassel Bach equation

Discuss the rules used for calculation and compensation

Discuss base deficit and how to correct

Differentiate between Alfa versus pH state

Describe ABG sampling techniques and pitfalls

Acid base disturbances


33


Interpret ABG

Take ABG sample

Use appropriate calculation methods for diagnosis and replacement therapy

Timely make appropriate decisions in the diagnosis and management after ABG

reading

Knowledge Trainees should be able to:

Discuss the principles of safe transfer of patients.

Describe various portable monitoring systems

Skills Trainees should:

Perform Intra-hospital transfer of patients requiring ventilatory support alone.

Perform Inter hospital transfer of patients with single or multiple organ failure.

Attitude and behavior Insist on stabilization before transfer.

Pre transfer checking of kit and personnel.

Anticipate and prevent problems during transfer.

Communicate with referring and receiving institutions and teams.

Insist on adequate support from senior / more experienced colleagues.

Knowledge

By the end of training, trainees will have adequate knowledge and deep understanding of:

Factors which predispose patients to critical illness, including poor nutrition.

Early warning signs of impending critical illness.

Methods of optimizing high risk surgical patients.

Criteria for admission to & discharge from intensive & high dependency (HDU) care

units.

Risk factors for ICU readmission following discharge to the ward.

Tracheostomy care outside the ICU or HDU.

Post-ICU mortality rate, and common reasons for death following discharge

Common symptomatology following critical illness .

Rehabilitation: physical and psychological .

Long-term or home ventilation .

Persistent vegetative state .

5-Transport of the critically ill patients

Pre- and post-ICU care


34

Skills

By the end of training, trainees will able to:

Perform Resuscitation and initial stabilization (see domain 1).

Recognize and manage risk factors associated with critical illness.

Manage Optimization of high-risk surgical patients before surgery

Liaison with ward staff to ensure optimal communication & continuing care after ICU

discharge.

Perform Timely discussion of ‘do not resuscitate’ orders and treatment limitation

decisions.

Identify complications associated with critical illness (e.g.: nerve palsies) and appropriate

referral.

Attitudes and behavior Be determined to provide best care possible regardless of environment.

Follow-up of patients following discharge to the ward.

Have Good communication and relationships with ward staff.

Knowledge


Causes of, and methods of minimizing distress to patients

Bereavement: anticipating and responding to grief

Methods of communicating with intubated patients

Methods of measuring depth of sedation

Stress responses

Causes and management of acute confusional states

Sleep deprivation and its consequences

Acute pain management

Patient-controlled analgesia

Indications, contra-indications and complications of commonly used analgesic, hypnotic,

and neuromuscular blocking drugs

Comfort care


35

Pharmacokinetics and dynamics of commonly used analgesic and hypnotic agents, and

neuromuscular blocking drugs in-patients with normal and abnormal organ system

function.

Indications, contra-indications, methods and complications of regional analgesia in critical

illness

Importance of mouth care

Skills

By the end of training, trainees will able to:

Identify and treat causes of distress

Safely use analgesic, hypnotic and neuromuscular blocking drugs

Manage appropriately established epidural analgesia

Minimize complications associated with opioid and non-opioid analgesics

Attitude and behavior Minimize patient distress

Work with nurses and relatives to minimize patient distress

Communicate with and support next-of-kin

Knowledge


Universal precautions and good working practices (hand washing, gloves etc) .

Proper handling of medical devices including intravascular devices .

Cross infection: modes of transfer and common agents.

Autogenous infection: routes and methods of prevention.

Emergence of resistant strains.

Antibiotic policies in a hospital.

Activity of commonly used antibiotics.

Common surgical infections: antibiotic choice and prophylaxis.

Infections from contaminated blood.

Hepatitis and HIV infections: modes of infection: natural history: at risk groups.

Immunization policy.

Sterilization of equipment.

Strategy if contaminated .


Recognize specific risk groups including immunocompromised patients .

Sepsis and infection control


36

Recognize the risk associated with administration of IV antibiotics: e.g. risk of allergy

and anaphylaxis etc.

Use appropriate aseptic techniques .

Use disposable filters and breathing systems .

Use protective clothing/gloves/masks etc .

Apply appropriate methods for preventing autogenous infection (e.g.: posture, mouth

hygiene) .

Attitude and behavior Appreciate that every patient is entitled to the best care available

Prevent self-infection

Appreciate that prevention of cross infection is their responsibility

Knowledge


Causes of, and methods of minimizing distress to patients

Bereavement: anticipating and responding to grief

Methods of communicating with intubated patients

Methods of measuring depth of sedation

Stress responses

Causes and management of acute confusional states

Sleep deprivation and its consequences

Acute pain management

Patient-controlled analgesia

Indications, contra-indications and complications of commonly used analgesic, hypnotic,

and neuromuscular blocking drugs

Pharmacokinetics and dynamics of commonly used analgesic and hypnotic agents, and

neuromuscular blocking drugs in-patients with normal and abnormal organ system

function.

Indications, contra-indications, methods and complications of regional analgesia in critical

illness

Importance of mouth care


Identify and treat causes of distress

End of life care


37

Safely use analgesic, hypnotic and neuromuscular blocking drugs

Manage established epidural analgesia

Minimize complications associated with opioid and non-opioid analgesics

Attitude and behavior be sincere towards minimization of patient distress

Work collaboratively with nurses and relatives to minimize patient distress

Aim to communicate with and support next-of-kin

Y3 (ICM1)

In this year the candidate will gain most of his knowledge, skills, and experiences managing all the

multidisciplinary critically ill case in such ICU. It the working place for the intensive care fellow.

Resuscitation, stabilization, clinical assessment, monitoring, investigation, performing required

and indicated procedures, discussing differential diagnosis, management, and discharge plane, all

should be mastered with competence though this year


a- Resuscitation and initial stabilization

Knowledge

By the end of training, trainees should have adequate knowledge and deep understanding of:

The patient at risk of critical illness including cardiopulmonary arrest.

The management of common medical emergencies (acute asthma, COPD, hypertension,

myocardial infarction, ventricular failure, hypotension and shock, hemorrhage).

The common causes for admission to intensive and high dependency care.

Triage and management of competing priorities.

Methods of maintaining a clear airway.

Indications for and methods of tracheal intubation.

The use of drugs to facilitate airway control.

Criteria for Selection of tube type (oral, nasal, armoured etc), diameter and length.

The Management of difficult intubation and failed intubation.

Methods of confirming correct placement of the endotracheal tube.

The methods for Insertion and use of oral airways face masks and laryngeal mask airway.

Causes of regurgitation and vomiting; prevention and management of pulmonary

2- Adult Intensive care medicine

Intensive care of general

medical conditions


38

aspiration.

Cricoid pressure.

Airway management in special circumstances, (head injury, full stomach, upper airway

obstruction, shock).

Indications for and methods of ventilatory support.

the recognition and Emergency treatment of life-threatening disorders of cardiac rhythm.

External cardiac massage.

Drugs: pharmacology and dosages of hypnotics, analgesics and relaxants.

Side effects of drugs used and their interactions.

Approaches to Monitoring during sedation/induction of anesthesia for endotracheal

intubation.

The Recognition and management of anaphylactic and anaphylactoid reactions.

the Recognition and management of inadvertent intra-arterial injection of harmful

substances.

Problems of the obese or immobilized patient.

Methods of securing adequate vascular access rapidly.

Skills

Trainees should appropriately perform the following skills:

Life support skills to ALS provider level.

Airway assessment and optimizing the patient’s position for airway management.

Airway management with mask and oral/nasal airways.

Support of ventilation using bag and mask.

Introduction and checking correct placement of laryngeal mask airway.

Appropriate choice and passage of oral endotracheal tubes.

Orotracheal intubation: (up to grade II Cormack-Lehane for SHOs).

Use of gum elastic bougie and stiletto.

9. Identifying correct/incorrect placement of tube (oesophagus, R main bronchus).

Interpretation of capnograph trace.

Failed intubation drill.

Rapid sequence induction/cricoid pressure.

External cardiac massage.

Percutaneous pericardial aspiration (emergency).

Obtaining vascular access sufficient to manage acute hemorrhage.

Fluid resuscitation and initial management of shock, including use of drugs.

Use of emergency monitoring equipment.

Safety checking of resuscitation equipment (see equipment section).

Management and avoidance of cardiovascular and respiratory changes during and after

intubation.

Attitudes and behavior Stick to the principles of Safety first and knowing limitations.


39

Always knowing the location of senior assistance.

Being clear in explanations to patient and staff.

Being reassuring to patients and relatives.

Consideration of ethical issues: e.g. patient autonomy, appropriateness of ICU

admission.

b- Clinical assessment

Knowledge


The Importance of clinical history in making diagnosis.

The Relevance of prior health status in determining risk of critical illness and outcomes.

the impact of drug therapy on organ-system function.

Physical signs associated with critical illness.

The inflammatory response in relation to organ-system dysfunction.

Infection and its relation to the inflammatory response.

Methods of obtaining clinical information.

Relative importance and interpretation of clinical signs.

Pathogenesis of multiple organ dysfunctions.

Principles of prevention of multiple organ failure.

Skills Candidates should be able to:

Obtain an accurate history of the current condition, comorbidities and previous health

status using appropriate sources of information.

Elicit and interpret symptoms and signs on clinical examination.

Perform Examination and care of the unconscious or confused patient.

Obtain and interpret information from case records, charts and ICU chart.

Document information in the case record in a structured and accessible manner.

Link clinical with laboratory information to form a diagnosis.

Establish a management plan.

Timely recognize impending organ system dysfunction.

Attitudes and behavior Manage patients in a compassionate and considerate manner.

Communicate effectively with other health care professionals to obtain accurate

information and plan care


40

c- Investigation, data interpretation and diagnosis

Knowledge By the end of training, trainees should have adequate knowledge and deep understanding of:

The use of laboratory tests to confirm or refute a clinical diagnosis.

Advantages and disadvantages of laboratory tests.

Indications for, and basic interpretation of:

Electrocardiographs of common dysrhythmias, infarction, pulmonary

hypertension/embolism, pericarditis, LVH.

Echocardiography.

Ultrasound examination.

Cardiovascular physiological variables.

Fluid balance charts.

Blood gas measurement.

Respiratory function tests.

Chest radiographs: collapse, consolidation, infiltrates (including ALI/ARDS),

pneumothorax, pleural effusion, pericardial effusion, position of cannulae, tubes or foreign

bodies, airway compression, cardiac silhouette, mediastinal masses.

X-rays of long bone, skull, vertebral and rib fractures.

CT and MRI scans of head demonstrating fractures/ hemorrhage.

Neck and thoracic inlet films.

X-rays of abdominal fluid levels / free air.

Microbiology: types of organisms; colonization vs infection; appropriate antibiotics use.

Hematology (including coagulation and sickle tests).

Blood grouping and X-matching.

Urea, creatinine, electrolytes (Na, K, Ca, Mg).

Liver function tests.

Drug levels in blood or plasma.

Endocrine function: diabetes, thyroid disorders, adrenal failure.

Skills

Bronchoscopic broncho-alveolar lavage in an intubated patient.

Diagnostic bronchoscopy in a non-intubated awake patient.

Lumbar puncture and CSF sampling.

Link clinical with laboratory information to form a diagnosis.

Establish a management plan based on clinical and laboratory information.

Document results of laboratory tests

Attitudes and behavior Communicate and collaborate effectively with all laboratory staff.

Avoid unnecessary tests

d- Organ system support and related practical procedures



41

Respiratory system

Indications for and methods of tracheal intubation.

Appropriate use of drugs to facilitate airway control.

Tube types (oral, nasal, tracheostomy etc), diameter and length.

Management of difficult intubation and failed intubation.

Methods of confirming correct placement of the endotracheal tube.

Methods for Insertion and use of oral airways face masks and laryngeal mask airway.

Indications and contraindications to tracheostomy and minitracheostomy.

Management of and complications associated with tracheostomy tubes.

Causes of regurgitation and vomiting; prevention and management of pulmonary

aspiration.

Cricoid pressure: indications and safe provision.

Airway management in special circumstances, (head injury, full stomach, upper airway

obstruction, shock, cervical spine injury).

Indications for and methods of mechanical ventilation.

Ventilatory modes: CMV, IRV, PRVC, SIMV, PS, CPAP, BiPAP, Non-invasive

ventilation.

Principles of extra-corporeal membrane oxygenation (ECMO).

Detection and management of complications of mechanical ventilation.

Detection and management of pneumothorax (simple and tension).

Insertion and safe management of chest drains.

Indications and methods of bronchoscopy via an endotracheal tube.

Indications and methods of bronchoscopy in a conscious non-intubated patient.

Principles of weaning from mechanical ventilation.

Cardiovascular system

Cardiopulmonary resuscitation to ALS provider level.

Peripheral and central venous cannulation.

Arterial catheterization.

Pulmonary arterial catheterization, oesophageal Doppler, transesophageal echo.

Principles of transvenous cardiac pacing.

Use of inotropic, chronotropic, vasodilator and vasoconstrictor drugs.

Use of intravenous fluids: crystalloids, colloids, blood and blood products.

Principles of intra-aortic counterpulsation balloon pump.

Renal system

Safe urinary catheterization.

Methods of preventing renal failure.

Investigation of impaired renal function.

Knowledge of nephrotoxic drugs.

Adjustment of drug doses in renal impairment/failure.

Renal replacement therapies.


42

Gastrointestinal system and nutrition

Principles of adequate nutrition in the critically ill patient, including vitamins, trace

elements, immuno nutrition.

Assessment of nutritional status (e.g.: skin-fold thickness, muscle wasting).

Selection of enteral or parenteral routes for nutrition.

Nasogastric cannulation.

Nasojejunal and percutaneous feeding tube insertion.

Sengstaken tube insertion.

Principles of support for the failing liver.

Prevention of stress ulceration.

Techniques for preventing microbial translocation.

Nervous system

Principles of management of closed head injury.

Principles of management of raised intracranial pressure.

Principles of management of vasospasm.

Indications for and use of information from intracranial pressure monitoring devices.

Musculoskeletal system

Prevention of pressure sores.

Principles of management of fluid losses following burns.

Short-term complications of fractures.

Consequences of muscle wasting.

Sepsis and infection:

Requirements for microbiological surveillance and clinical sampling.

Relation between lab results and patient's condition.

Appropriate use of antibiotics.

Proper handling of invasive medical devices.

Skills

Trainees should be able to perform the following:

Maintenance of a clear airway using bag and mask.

Orotracheal intubation.

Naso-tracheal intubation.

Percutaneous tracheostomy.

Minitracheostomy or needle cricothyoidotomy.

Changing an orotracheal tube.

Changing a tracheostomy tube electively.

Manual bagging and tracheal suction.

Institution and maintenance of controlled mechanical ventilation in a critically ill

patient.

Confirmation of adequate oxygenation and control of PaCO2 and pH.

Aseptic insertion of a pleural chest drains and connects to a one-way seal device.

Establish peripheral venous access sufficient to manage major hemorrhage.

Aseptic insertion of central venous, pulmonary arterial and arterial catheters.

Aseptic insertion of tunneled central venous catheter for parenteral nutrition.

Appropriate use of intravenous fluids.


43

Appropriate use of infused vasoactive drugs.

Measurement of cardiac output using pulmonary artery catheter or oesophageal

Doppler.

Identification and avoidance of factors contributing to impaired renal function.

Urinary catheterization: male and female.

Nasogastric tube placement.

Management of cardiorespiratory physiology to minimize rises in intracranial

pressure.

Recognition and temporary stabilization of unstable cervical spine.

Attitudes and behavior Appreciate the importance of ensuring physiological safety as a primary aim..

Recognize the difference between organ system support and specific treatment.

Appreciate the importance of timely institution of organ-system support.

Call for senior/more experienced help when experiencing difficulties.

Consider patient comfort in performance of practical procedures.

e- Monitoring and clinical measurement 1-Knowledge Trainees should have adequate knowledge and deep understanding of:

The role of clinical assessment in monitoring.

Physical principles underlying use of monitoring devices (see physics and measurement).

Indications for and contraindications to the use of monitoring devices.

Interpretation of information from monitoring devices, and identification of common

causes of error.

Principles of 'minimal monitoring'.

Complications associated with monitoring and monitoring devices.

Methods for measuring temperature.

Methods for assessing pain and sedation.

One general method for measuring severity of illness (severity scoring systems).

Methods for severity scoring or case mix adjustment for trauma, burns, therapeutic

intensity or costs.

Glasgow Coma Scale.

2-Skills Safe use of and interpretation of data from:

Pulse oximetry.

ECG (3- and 12-lead).

Non-invasive arterial blood pressure measurement.

Invasive arterial blood pressure measurement.

Central venous pressure measurement.

Pulmonary artery catheters or oesophageal Doppler.

Jugular bulb catheters and SjO2 monitoring.

Arterial blood gas sample handling.

Inspired and expired gas monitoring for O2, CO2, and NOi.

Spirometry and peak flow measurement.


44

Ventilator alarms.

Intracranial pressure monitoring.

Nerve stimulator to measure therapeutic neuromuscular block.

Clinical assessment of pain.

Scoring or scaling systems to assess degree of sedation.

Collection of data for one general method for severity scoring or case mix adjustment.

3-Attitudes and behavior

Ensure safe use of monitoring equipment in an appropriate environment.

Minimize patient discomfort in relation to monitoring devices.

Support other staff in the correct use of devices.

Review regularly the need for continued monitoring.

f- Safe use of equipment

1- Knowledge Trainees should have adequate knowledge and deep understanding of:

Airways, tracheal tubes, tracheostomy tubes, emergency airways, laryngeal masks, fixed

and variable.

Performance oxygen therapy equipment, self-inflating bags.

Humidification and nebulizing devices.

Modes of ventilation and method of operation of at least one positive pressure ventilator,

one non-invasive ventilator, and a constant positive airway pressure (CPAP) device.

Principles of use of pressure regulators, flowmeters, vaporizers, breathing systems.

Principles of disconnection monitors.

Manufacture, storage and safe use of oxygen, nitric oxide (NOi), compressed air and

helium.

Pipeline and suction systems, gas cylinders.

Non-invasive monitoring devices.

Methods for checking ventilator, breathing systems and monitoring apparatus.

Environmental control of temperature, humidity, air changes and scavenging systems for

waste gases and vapors.

Sterilization and cleaning of equipment.

Electrical safety.

Characteristics and safe use of vascular access cannulae, spinal needles, epidural catheters,

chest drains.

Function and use of defibrillator and other resuscitation equipment, transfusion devices.

Function and use of continuous haemodiafiltration devices

2-Skills Trainees should be able to perform the following:

Checking and setting the ventilator.

Checking pipelines, checking and changing cylinders.

Connecting and checking breathing systems.


45

Setting alarm limits for monitoring equipment.

Identifying and correcting ventilator miss-assembly and disconnections.

Collecting data from monitors.

Record keeping.

Checking, assembling resuscitation equipment.

Safe defibrillation.

Preparing equipment for:

Difficult and failed intubation.

Pediatric intubation set.

Aseptic vascular access.

Intravascular pressure monitoring.

Choosing appropriate fluid balances using renal replacement therapies.

3-Attitudes and behavior Shared responsibility for equipment with nursing and technical staff.

Determination to maximize safety.

Rapid response to acute changes in monitored variables.

THEORETICAL TOPICS

By the end of this year the candidate should have gained a vast and updated date and knowledge

about the following topics

1. Acid base disturbances

2. Water and electrolyte disturbances

3. Scoring system

4. Respiratory failure

5. Statue asthmaticus

6. Smoke inhalation and aspiration syndrome

7. Oxygen therapy

8. Pulmonary mechanics and gas exchange

9. Pathophysiology of mechanical ventilation

10. Conventional modes of mechanical ventilation

11. New modes of mechanical ventilation

12. Indications and complications of mechanical ventilation

13. Weaning of mechanical ventilation

14. Non invasive mechanical ventilation

15. Massive hemoptysis


17. Ventilator associated pneumonia(VAP)

18. Hemodynamic monitoring

19. Acute coronary syndrome


46

20. Arrhythmias

21. Heart failure- pulmonary edema

22. Hypertensive emergencies

23. Shock

24. Vasoactive drugs in critically ill

25. Aortic dissection

26. Neuro- monitoring

27. Cerebro-vascular stroke

28. Convulsions in ICU

29. Coma

30. Neuromuscular disorders in critically ill

31. Delirium in ICU, acute psychosis, neuroleptic malignant syndrome

32. GIT hemorrhage

33. Hepatic failure

34. Acute pancreatitis

35. Abdominal compartmental syndrome

36. Ileus and motility disorders


38. Renal replacement therapy

39. Sepsis syndrome

40. Multiple organ dysfunction syndrome(MODS)

41. Anemia in critically ill

42. Blood and blood product transfusion

43. Bleeding and coagulation disorders

44. Diabetic emergency

45. Adrenal crisis

46. Thyroid storm and Myxedema coma

47. Microangiopathy hemolytic anemia’s(TTP HELLP--),

48. Near drowning and electric burn

49. Eclampsia

50. Total parental nutrition(TPN)

CLINICAL CASES

By the end of this training, candidate should have gained experience in the evaluation and

management of the diverse systems encountered in intensive care units that include the following

areas:

1. Management of acute respiratory failure

2. Traumatology cases

3. Metabolic &electrolyte disturbances

4. Sepsis & infection control

5. Acute coronary syndrome, dysrhythmias & cardiac pacing

6. Neurology& C.V. strokes

7. Nephrology& acute renal failure

8. Nutrition (Enteral & parenteral)

PROCEDURES By the end of this year the candidate should be handle the following procedures with high

competence and performance.


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1. Central venous line placement

2. Endotracheal Intubation

3. Arterial line placement

4. Mechanical ventilation

5. Intercostal tube Insertion

6. Tracheotomy

7. Cardiac pacing

8. Venous cut down

9. Pulmonary artery catheter

WORKSHOPS By the end of this year the candidate should have attended and passed successfully the following

workshops


2. Acid base

3. Nutrition

Y4 &Y5 (ICM3&ICM4)



The signs and symptoms that suggest life threatening or critical illnesses in neonates,

infants and children.

2. Management of cardiopulmonary arrest including basic and advanced life support.

The etiology, pathophysiology, clinical presentation and management of different types of

shock.

The etiology and clinical presentation of different types of coma in infants and children.

Causes and clinical presentation of childhood poisoning.

Initial management of burns, drowning and traumatized children.

The etiology, clinical presentation and management of acid base disturbances and

electrolyte imbalance.

Types and indications for mechanical ventilation.

The causes and management of childhood pain.

Ethical issues related to pediatric Intensive Care like withholding or withdrawal of life

support.

Intellectual and professional skills Trainees will be able to:

1. Recognize neonates, infants and children with critical or life threatening presentation

related to any body organ/system.

Take focused history and performs timely appropriate clinical examination for children in

the ER and in pediatric ICU.

3. Assess infants and children for fluid needs and manage different degrees of

1- Pediatric intensive care medicine


48

dehydration.

Differentiate between types of electrolyte disturbances and manage appropriately.

5. Differentiate between various types of acid base disturbances and manage

appropriately.

Perform cardiopulmonary resuscitation in the field and in the ICU.

Assess and manage different types of shock.

8. Recognize , assess and initiate management for infants and children with different

organ/ system failure

Assess and manage different types of pain in infants and children system failure.

Initiate management and refer appropriately infants and children presenting with burns,

multiple traumas and pediatric surgical emergencies.

Recognize and initiate management for infants and children presenting with uncommon

emergencies like drowning, cold injury, and electric injury, psychiatric and gynecological

emergencies.

Initiate mechanical ventilation.

Communicate effectively with parents and children in critical situations like the need to

withdraw life support or when delivering bad news.

advise parents about prevention of childhood injuries.

THEORETICAL TOPICS

By the end of this training period the candidate should have gained an updated date and knowledge

about the following topics

1. The critically ill infant and child.

2. Respiratory emergencies.

3. Cardiac emergencies.

4. Renal emergencies.

5. Neurological emergencies.

6. Metabolic emergencies.

7. Hepatic failure.

8. Hematological emergencies.

9. Fluid replacement therapy.

10. Acid- base disturbances

11. Shock.

12. Mechanical ventilation.

CLINICAL CASES

By the end of this training period candidate should be able to diagnose and manage with high

perfection the life threatening aspect of the following cases:

1. Respiratory emergencies

i. Upper airway diseases 1. Stridor.

2. Foreign body inhalation

ii. Lower airway diseases

1. Wheezy infants and bronchial asthma

2. Pneumonia , effusion and pneumothorax

iii. Respiratory failure due to various causes

2. Cardiac vascular emergencies i. Heart failure

ii. Arrhythmias


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iii. Hypertension

iv. shock

3. Neurological emergencies v. Coma

vi. Convulsions

4. Metabolic emergencies: Diabetic ketoacidosis

5. Hematological emergencies

vii. Anemia

viii. DIC

6. Child abuse

PROCEDURES

1. PACLS


3. Intravascular access

a. Peripheral

b. Central

c. Intraosseous

4. Chest tube

5. Ascites tap

6. Urinary catheter

7. Nasogastric tube

8. Oropharyngeal suction

9. Blood products

10. Total parenteral nutrition

Y4 &Y5


Upon completion of training, Y4 & Y5 the fellow should be able to:

Patient Care

Demonstrate competency in the initial assessment, triage, and resuscitation of injured

patients

Demonstrate competency in airway assessment and management, including rapid sequence

intubation (RSI) and cricothyroidotomy

Demonstrate competency in recognizing and managing thoracic injury, including simple

and tension pneumothorax, [massive] hemothorax, rib fractures and flail chest, pulmonary

contusion, and great vessel injury

Demonstrate familiarity with such procedures as needle chest decompression and tube

thoracostomy

Demonstrate competency in appropriate performance of emergency thoracotomy

Demonstrate appropriate use of crystalloids and blood products for resuscitation

Demonstrate competency in implementing massive transfusion protocol

2-Trauma and burns


50

Cite the advantages and disadvantages of endpoints of resuscitation, including vital signs

and other physical examination findings, base deficit, lactate levels, and global oxygen

delivery and consumption variables

Demonstrate familiarity with the type and placement of vascular access and the use of

massive transfusion devices

Demonstrate competency in diagnosing intra-abdominal injury, including the use of

focused assessment with sonography in trauma (FAST) examination and diagnostic

peritoneal lavage

Demonstrate competency in recognizing and managing abdominal compartment syndrome

and temporary abdominal closure techniques

Demonstrate competency in the diagnosis and management of pelvic fractures, including

recognition of associated injuries

Demonstrate competency in the management of patients with traumatic brain injury, spinal

cord injury, and blunt cerebrovascular injury, including the selection and use of intracranial

pressure monitoring devices and other brain monitoring devices

Demonstrate competency in appropriate timing and selection of radiographic studies in the

evaluation of the injured patient

Demonstrate the ability to interpret radiologic and laboratory data to develop

comprehensive management plans

Demonstrate comprehensive knowledge relevant to specific trauma patient populations

(e.g., pediatric, geriatric, and obstetric) including:

Methods of preventing the 'second insult' to the brain.

Management of cervical spine injuries.

Soft tissue injury related to fractures.

Crush injury and compartment syndromes.

Calculation of area burned.

Prevention of infection in the burned patient.

Detection and management of smoke inhalation or airway compromise.

Fluid resuscitation in the burned patient.

Medical Knowledge

Explain the significance of mechanism of injury in the care of the injured patient

Differentiate between blunt and penetrating mechanisms of injury

Explain the specific concerns in the care of the injured pediatric, geriatric, or obstetric

patient

Cite the principles of initial trauma evaluation and management

Describe the different types of thoracic injury and appropriate management strategies for

each, including initial and subsequent interventions

Cite the principles and practice of nonoperative management of solid abdominal organ

injury, including injury grading scales

Describe the causes and pathophysiology of elevated intra-abdominal pressure and

abdominal compartment syndrome, as well as principles and complications of temporary

abdominal closure

Describe the pathophysiology of various types of traumatic brain injury (including

epidural, subdural, intraparenchymal hemorrhage, diffuse axonal injury), and explain

techniques for preventing secondary brain injury

Describe the pathophysiology of intracranial hypertension and its management, including

the use of ICP monitoring devices, extraventricular drains, and operative intervention


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Cite key considerations in the management of patients with CNS injury, including fluid

selection, nutrition, management of coagulopathy, DVT prophylaxis, and such

complications as diabetes insipidus, cerebral salt wasting, and the syndrome of

inappropriate antidiuretic hormone release.

Describe the mechanisms and clinical signs and symptoms of blunt cerebrovascular injury,

and explain potential treatment strategies for these patients

Explain the pathophysiology of spinal cord and spinal column injury and its clinical

presentation, and describe management considerations (including complications) for these

patients

Describe clinical issues associated with spinal cord injury (e.g., cardiovascular and

ventilator considerations, tracheostomy, DVT prophylaxis, skin integrity, and contracture)

Demonstrate competency in managing extremity fractures, including optimal timing of

fracture fixation, recognition of associated vascular and neurologic injuries, and

recognition and prevention of compartment syndrome

Cite the complications associated with extremity injuries, including rhabdomyolysis, fat

embolism syndrome, and compartment syndrome

Explain key considerations in evaluating and managing the patient with a mangled

extremity, including the use of appropriate scores and adjunctive measures

Explain the significance of different types of pelvic fractures, and demonstrate competency

in management of associated injuries (e.g., urethral trauma and open fractures)

Cite the indications for and complications of blood component therapy and application of

massive transfusion principles

Practice-Based Learning

Describe measures and techniques for improving trauma system performance, including

review of specific indicators (e.g., delay to operative intervention)

Review published information critically to understand current evidence-based information

to optimize resuscitation (e.g., fluid selection, blood pressure control), select appropriate

radiographic imaging, and tailor care to specific problems (e.g., thoracic aortic injuries or

prevention of secondary brain injury)

Interpersonal and Communication Skills

Demonstrate effective communication with emergency medicine colleagues, nurses,

respiratory therapists, and consulting services for collaborative management of the injured

patient

Demonstrate effective communication with patients and family members, both listening

and conveying information with appropriate degree of complexity

Develop collaborative relationships with consulting services for optimizing the timing of

interventional procedures

Professionalism

Demonstrate respect, compassion, integrity and responsiveness to the needs of the patients

and their families

Approach discussions of ethical issues (including advanced directive and end-of-life issues)

with sensitivity

Demonstrate accurate self-assessment, knowledge of professional limits, and an ongoing

desire for self-improvement


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Systems-Based Practice

Demonstrate an understanding of the impact of a trauma system on regionalization of

trauma care

Demonstrate understanding of cost-effective patient care in a tertiary care hospital setting

Participate actively in triage decision-making in the setting of multiple casualties

Serve as an advocate for quality patient care with due attention to costs and resources

Partner appropriately with other health care providers, including consulting physicians,

nurses, pharmacists, respiratory therapists, and physical and speech therapists

Demonstrate understanding of the role of discharge planning and selection of appropriate

discharge venue (rehabilitation facility vs skilled nursing facility vs home)

Skills Assessment and immediate stabilization of the trauma patient: primary survey.

Assessment and immediate stabilization of the trauma patient: primary & secondary

survey.

Calculation and documentation of Glasgow coma scale.

Recognition of need for appropriate investigations (Hb, cross-match, chest X-ray, CT scan

etc).

Assessment, prediction and management of circulatory shock.

Emergency airway management, oxygen therapy and ventilation.

Chest drains insertion & management: emergency relief of tension Pneumothorax.

Cannulation of major vessels for resuscitation and monitoring.

Care and immobilization of cervical spine.

Analgesia for the trauma patient.

Urinary catheterization in pelvic trauma.

Differentiate & manage tension Pneumothorax, cardiac tamponade, and pulmonary

embolus.

THEORETICAL TOPICS

This course will cover the following lectures in addition to the rotation in the intended mono

disciplinary intensive care in year 4 and 5

Surgical management of head injury

Intensive care management of head injury

Surgical management of chest injury

Intensive care management of chest injury

Management of abdominal trauma

Management of spinal cord trauma

Management of face trauma

Management of wound

Surgical management of burns

Intensive care management of burn

Antibiotic therapy in burn, elective surgery and trauma patient

CLINICAL CASES All cases of trauma admitted to the surgical causality intensive care whether mono or poly trauma

should be managed and in collaboration with the intended subspecialty

Y4&Y5

3- Surgical post operative intensive care


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A. General factors:

Importance of preoperative health status on postoperative outcomes.

Factors determining perioperative risk, and methods of optimizing high-risk patients.

Implications for postoperative care of type of surgery.

Implications for postoperative care of type of anesthesia.

Anesthetic risk factors complicating recovery: suxamethonium apnea, anaphylaxis,

malignant hyperpyrexia, difficult airway.

Dangers of emergency anesthesia.

The interpretation of relevant preoperative investigations.

Effect of gastric contents, smoking, and dehydration on perioperative risk.

Implications for postoperative care of common medical conditions (see section on

general medical conditions).

Implications of current drug therapy.

Need for and methods of perioperative anti-thrombotic treatment.

Assessment of post-operative analgesic needs.

Management of cyanosis, hypo- and hypertension, shivering and stridor.

Assessment of pain and methods of pain management.

Methods of treating of postoperative nausea and vomiting.

Causes and management of post-operative confusion.

Assessment of appropriate level of postoperative care: ICU, HDU, post-anesthesia

recovery.

The importance of consent and the issues surrounding it.

B. Respiratory:

Interpretation of symptoms and signs of respiratory insufficiency in the surgical patient; the

unprotected airway; upper and lower airway obstruction including epiglottitis; pneumonia,

collapse or consolidation, pulmonary infiltrates including acute lung injury (ALI) and the acute

respiratory distress syndrome (ARDS) and their causative factors; pulmonary edema; pleural

effusion, pneumothorax (simple and tension); use of chest drains; factors affecting patients

following thoracotomy, lung resection, oesophagectomy, cardiac surgery and thymectomy.

C. Cardiovascular:

Interpretation of symptoms and signs of cardiovascular insufficiency in the surgical patient;

operative risk factors in patients with ischemic heart disease; pulmonary embolus; cardiac

tamponade; management of patients following cardiac surgery (coronary grafting, valve

replacement) and aortic surgery (thoracic descending, abdominal); heart and heart-lung

transplantation.

D. Renal:

Causes of perioperative oliguria and anuria; prevention and management of acute renal failure;

consequences of nephrectomy, ileal conduits.

E. Gastrointestinal:


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Interpretation of abdominal pain and distension; peptic ulceration and upper GI hemorrhage;

diarrhea, vomiting and ileus; peritonitis; intestinal ischemia, abdominal tamponade; pancreatitis;

jaundice; management of the post-liver transplant patient; perioperative nutrition.

F. Neurological:

Surgical causes of confusion, coma and raised intracranial pressure; determinants of cerebral

perfusion and oxygenation; prevention of secondary brain injury; perioperative management of

patients with neuropathies and myopathies (e.g.: thymectomy); intracranial pressure monitoring;

intracerebral hemorrhage; spinal cord and brachial plexus injury.

G. Sepsis and infection:

Pyrexia and hypothermia; wound infections; necrotizing fasciitis; prophylactic antibiotics; risk

of infection in patients with indwelling medical devices including intravascular and urethral

catheters and heart valves; peritonitis; intestinal ischemia.

H. Hematology and oncology:

Care of the immunosuppressed or immunoincompetent patient; management of severe acute

hemorrhage and blood transfusion; coagulation disorders and hemoglobinopathies

I. Metabolic and hormonal:

Perioperative management of patients with diabetes; hypo- and hyperadrenalism, surgery to

thyroid, adrenal and pituitary glands; perioperative electrolyte disorders.

J. Musculo-skeletal:

Trauma patients (see trauma section); pressure area care; compartment syndromes; paralyzed

patients.

Skills Obtain information from sources other than the patient.

Identify airway or intubation difficulties, preoperative health status and intercurrent

disease, medications, allergies, nature of anesthetic and surgery.

Assess conscious level, status of airway and cervical spine, and conduct careful systems

review.

Determine adequacy and route of administration of analgesia.

Document, monitor and manage fluid balance, circulating volume, drains, systemic

oxygen supply.

Identify life-threatening cardio respiratory complications, and manage hypovolemia.

Differentiate and manage tension Pneumothorax, cardiac tamponade, and pulmonary

embolus.

Attitudes and behavior Establish a plan for postoperative management.

Ensure the necessary resources are available for safe postoperative care.

Communicate effectively to establish care plan with anesthetist, surgeon, nursing staff

and other professionals, and with relatives and patient where appropriate.

THEORETICAL TOPICS Organ transplantation:

Indications for transplantation of heart, kidney, and liver

Immunosuppression


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Infections in the immunocompromised patient

Organ rejection early and late

Organ donation

Bone marrow transplantation complications

Post operative management of brain and spinal cord surgery

Post operative management of open heart surgery

Post operative management of liver transplantation

Post operative management of renal transplantation

Post operative of major abdominal surgery

CLINICAL CASES

Intensive Care Post Operative Liver Transplantation (2 M)

1. Post operative cases

2. I.C.U Post transplantation complication cases

Intensive Care Neurosurgery Cases (2M)

1. Brain

2. Spinal cord

Intensive Care Post Operative Open Heart (2M)

1. CABG

2. Valve replacement

3. Open heart operations

Post Operative General Intensive Care (2M)

Different cases

Y4 & Y5



The recognition, evaluation and management of critically ill patients as part of an

intensivist-led multidisciplinary team.

Assessment and management of common ICU problems/syndromes/diseases will be

emphasized.

The management of the ventilator for common conditions, including asthma, COPD,

pneumonia, CHF, and ARDS.

The management of acute coronary syndrome, heart failure, arrhythmias, and

conduction defects

The management of cases with peritoneal dialysis, hemodialysis, and ultra filtration.

4-Medical intensive care


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The management of CVS, convulsions, Myopathies, and neuropathies

The scientific evidence behind treatment of common critical care conditions.

The indications and contraindications for common critical care procedures, including

central line placement, pulmonary artery catheterization, dialysis, arterial line

placement, thoracentesis, intubation, and non-invasive ventilation

Skills

Obtain information from sources other than the patient.

Identify airway or intubation difficulties, and discuss ventilation data and

complications

Assess conscious level, neurological status, and plan for the management of the case

and the anticipated complications

Determine adequacy and route of administration of analgesia. and other drugs and

discuss its actions and interactions

Document, monitor and manage fluid balance, circulating volume, drains, and

systemic oxygen supply.

Identify life-threatening complications in every patient according to his

pathological status

Access and critically evaluate current medical information and scientific evidence.

Attitudes and behavior Develop a good working relationship and rapport with other physicians, health

Professionals, patients, and families.

Communicate effectively, including presenting cases precisely and efficiently

Maintain comprehensive, timely and legible medical records.

Participate in daily sign-out rounds

Demonstrate interest in learning, and apply and open-minded and analytical approach

to acquiring knowledge.

THEORETICAL TOPICS

1. Microcirculatory failure in critically ill

2. Gastro-enteropathy in critically ill

3. Immunological response in critically ill

4. Immuno – inflammatory crosstalk in critically ill

5. Coagulopathy in critically ill

6. Coagulation – inflammation crosstalk in critically ill

7. Protective lung strategies in ventilated, COPD, ARDS, & Bronchial asthma

8. Regional perfusion pressure in critically ill

9. Priorities in resuscitation

10. Antibiotic therapy guidelines in critically ill

11. Impact of mechanical ventilation on cardiac function

12. Lung mechanics and its impact on ventilator adjustment variables

13. Protective brain strategies in critically ill

14. Protective renal strategies in critically ill

15. Post arrest syndrome

16. Calcium homeostasis in critically ill

17. Rejection and organ transplant

18. Waveform analysis of ventilated patient

CLINICAL CASES


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Intensive Care Cardiology (3M) 1. Acute coronary syndrome

2. Cardiac arrest

3. Right sided heart failure

4. Left sided heart failure (rheumatic, ischemic, cardiomyopathic)

5. Cardiogenic shock

6. Atrial arrhythmia

7. Ventricular arrhythmia

8. Pericarditis

9. Artificial valve dysfunction

10. Hypertension

Intensive Care Pulmonology Cases (2M) 1. Adult respiratory distress syndrome (ARDS)

2. Respiratory failure (COPD)

3. Respiratory failure (status asthmaticus)

4. Respiratory failure (pneumonia)

5. Severe community acquired pneumonia (CAP)

6. Ventilator associated pneumonia (VAP)

7. Aspiration pneumonia


9. Pneumothorax

10. Respiratory failure in special situations ( e.g. pregnancy)

11. Hemoptysis

Nephrology (Dialysis) (1M) 1. Hemodialysis

2. Ultra filtration

3. Peritoneal dialysis

Intensive Care Neurological and neuromuscular cases (2M) 1. Epilepsy

2. Cerebro vascular stroke

3. Spinal cord injuries (traumatic, vascular…)

4. Guillain Barré syndrome

5. Myasthenia gravis

6. Coma

7. Vegetative state

8. Myopathy

9. Neuropathy

Critical Care Training (6M) 1. Management of acute respiratory failure

2. Trauma cases

3. Metabolic & electrolyte disturbances cases

4. Sepsis& Infection control

5. Acute coronary syndrome, Dysrhythmias& Cardiac pacing

6. Neurology & C.V. Strokes

7. Nephrology& Acute renal failure

8. Toxicology

9. Nutrition


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PROCEDURES & SKILLS

As a part of the ICU experience is the performance of the multiple procedures needed for the

evaluation, monitoring, and care of patients. After being competent in performing a lot of

procedures along the previous training years , Candidate will be instructed and supervised in the

planning and performance of the following procedures,

1. Abdominal lavage

2. FAST

3. Cardiac pacing

WORKSHOPS

By the end of these training years Y4and Y5 the candidate should have finished the following

workshops

1. ATLS

2. PACLS

3. Echocardiogram (trans-esophageal)

5- Toxicology

Knowledge 1. Explain The epidemiology of poisoning in Egypt and define the common types of

ingestions in adults.

2. Describe The clinical features of common poisons and the principle of their

management (e.g. salicylate poisoning, Paracetamol, antidepressants, etc).

3. Highlight The medicolegal aspects of poisoning and what physicians should do to

protect their patients.

4. Describe The role of gastric lavage, activated charcoal, alkalinization and antidote

in the management of poisoning.

5. List The common types of environmental emergencies seen by internist and

outline their clinical manifestations and methods of treatment.

Skills 1. Recognize the symptoms and signs suggestive of poisoning, stabilize the patients

and call for help through immediate contact with poisoning centers.

2. Carefully obtain drug history from patient and relatives to identify the causative

agent.

3. Perform gastric lavage only when indicated.

4. Recognize cases suggestive of drug abuse stabilize and consult or refer to

toxicology centers, in the mean time the physician should involve appropriate

authorities.

5. Stabilize and resuscitate patients using The ABCDE approach.

6. Provide specific treatment if available or ensure safe referral.

7. Identify associated complications if present.

8. In case of scorpion or snake bite, he should be able to recognize the bite &

initiate treatment through the immediate provision of passive immunization.

Lectures


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1. General principles of management of acute poisoning

2. Corrosives

3. Animal poisoning

4. Food poisoning

5. Toxic gases exposure

6. Pesticides

7. Sedatives and hypnotic poisoning

8. Analgesic poisoning

9. Digitalis poisoning

10. Antipyretic poisoning

11. Antipsychotic poisoning

12. Antidepressant poisoning

13. Narcotic poisoning

METHODS OF ASSESSMENTS

REGULATIONS

The general rules and regulations of assessment approved by the Egyptian fellowship board and

published at the training handbook and also the board web site applies for the intensive care

specialty. In addition to the successful completion of the training program, all candidates must

successfully pass three exams in order to get the fellowship certificate.

First part Exam: The first part exam is a written exam. Trainees are allowed to sit for the first

part exam after 18 months of training. Each candidate has three chances to pass the exam and one

more additional chance may be granted in some special circumstances approved by the secretary

general of the higher committee of medical specialties. It is to be noted that after 18 months of

training each time the candidate will choose not to enter the exam will be calculated as one of

his three attempts.

Second part exam: The second part exam is a written exam. Trainees are allowed to sit for the

second part exam after passing successfully the first part and after completion of the training

period (five years). In addition, each candidate must submit his log book for final assessment. The

log book requirements must all be completed and signed by the trainer and educational supervisor.

Each candidate has three chances to pass the exam and one more additional chance may be granted

in special approved circumstances.

Clinical Exam (third part): The third part exam is a clinical and oral exam. Candidates who pass

successfully the second part are allowed to sit for the third part. Again each candidate has three

chances to pass the clinical exam and an additional fourth chance may be granted in special

approved circumstances.

Pre‐ requisites for entering the first part exam

Trainees should pass the following courses in order to be eligible for the first part exam 1. Local TOEFEL with a score of at least 500

2. Computer courses in word processing, spread sheets, internet and power point


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STRUCTURE OF THE EXAMINATION

The first part exam aims to test trainee's knowledge in basic science and different subspecialties of

internal medicine as it is mentioned in this curriculum.

The structure of the first part exam: PART I examination consists of two papers:

1- Paper I (2 hours): Multiple choice questions with a single best answer format. This paper will

cover applied basic sciences mentioned in the curriculum.

2- Paper II (2 hours): short answer and /or problem solving questions and this paper test trainees'

knowledge in the basics of internal medicine subspecialties that must be covered during the first

two years of training. The second part exam aims to test trainees' knowledge and skills in internal medicine. In this exam all

the internal medicine curriculum will be covered.

The structure of the second part exam: Part II examination consists of four papers:

1. Two MCQ papers each two hours in duration. They are covering all intensive care specialties. In

both papers, facts, problem solving and management skills are going to be assessed. You will

choose one best answer in each question 2. Two short assay papers each two hours in duration. They cover all intensive care subspecialties.

Questions will assess Trainees' knowledge about various diseases and their management. In addition, it

will test students' problem solving skills.

The structure of the third part exam: part III exam is a clinical and oral exam and is composed of

the following components:

1. Clinical exam

The clinical exam remains the most important part of the examination as the long case evaluate the

potential performance of the candidate in clinical practice while short cases assess clinical

examination skills in various system. Passing this component of the exam independently is

essential for certification.

1.1. Long Clinical Case : the candidate is observed in silence for the first part of the

examination by two examiners where he/she is taking the history from the relatives or the

patient and performing a physical examination and then the examiner asks the candidate to

present the finding, in history , examination and discuss the management of the case .

Marks are given according to a predetermined weighting of the components of the exam.

1.2. Clinical OSCE (Objective Structured Clinical Examination) this has replaced the

traditional short cases. Each candidate examines four or five patients. The examiners

evaluate his abilities to correctly elicit and interpret physical signs. An agreed marking

system is used to ensure objectivity and fairness of the exam.

1.3. OSPE is a multiple station examination including ECG/ X-ray / CT Scans/ laboratory

data results / skin photographs / karyotypes etc set as 10-20 OSCE stations. The candidate

rotates from station to station where he / she are tested on a specific element that measures

his data interpretation skills.

1.4. VIVA: The oral exam which tests the candidates’ ability to manage patients and

explores his/her knowledge of making an accurate diagnosis and whether he/she

understands the essentials of therapeutics. It also assesses his attitudes and interpersonal

communication skills. It is based on a set of topics with opening and supplementary

questions. The questions cards are prepared in advance together with the expected ideal

answer and allocated marks. This allows a good objective basis for marking.


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