STUDENT ORIENTATION

CRITICAL CARE, AFTERHOURS AND EMERGENCY MEDICINE
Veterinary Teaching Hospital

Colorado State University

Student rotations in critical care and emergency medicine will provide experience in dealing with animals requiring close monitoring and observation. These animals have a variety of problems necessitating a broad base of experience and expertise. Students are not afforded the luxury of studying a single organ system. Instead, many of our animals have multiple organ system involvement. The purpose of this document is to acquaint the student with policies, procedures, and expectations for your rotations in veterinary critical care and emergency medicine.

CRITICAL CARE ROTATION

The main objective of the critical care rotation is to provide optimal patient care. Veterinary patients will be assigned to students on this rotation. For each patient, the student will have the following responsibilities:

1. Provide excellent patient care. Each animal will be kept clean, be bathed as necessary, and will always have a clean cage.
 
2. Provide monitoring, administer medications, nutrition, water, and perform diagnostic procedures as prescribed by the primary clinician in charge of the case.
All ordered parameters will be completed and documented on the CCU Flow Chart. The CCU student will be expected to complete all orders beginning with the 7:00 AM treatments. Obviously, this will require early arrival at the VTH (plan to arrive in CCU no later than 6:30 AM!).
 
3. Provide written orders, a daily physical examination, a treatment flow sheet, and patient transfer card for each animal. These will be written and prepared prior to all morning rounds discussion periods.
 
4. Each day, the CCU student will initiate a patient problem card. This card will have the blue card stamped in the upper right corner, will identify the students involved with the case, and will identify all problems in the patient. As the case is transferred from one group to the next, the problems will be updated and the card will then be given to the CCU clinician by the EM student at the 7:30 AM rounds. If an animal comes in after the CCU student has left for the day, the student on the afterhours or EM rotation will intitiate the card and pass it along.
 
5. Daily CCU order sheets will be written by the student assigned to the case. These orders will be an opportunity for the student to provide input on the monitoring, treatment, and management of the case. The primary clinician in charge of the case will review the orders, check dosages, and signify approval by signing the record. Once the record is signed, all procedures will be completed and recorded as directed. If changes are to be made in the orders, communication between the clinician and student is required. If in doubt, ask for advice!
 
6. CCU students will present each of their assigned cases in daily rounds. The format of these presentations will be as follows:
a. Patient signalment
b. Brief history pertinent to the animal's being in CCU
c. List of problems the animal is being treated for
d. Abnormal results from objective data for each problem. Make every effort to have radiographs, ECGs, ultrasound, CT scans, nuclear medicine scans, etc available for review by all participants.
e. Important ruleouts and changes in each problem
f. Plan for each problem
Rounds for the EM students will be held at 7:30 AM (Monday - Friday). These rounds will update the CCU clinician on progress of each animal through the day. Rounds on weekends and holidays will be held at 7:30 AM for EM and CCU students. Daily CCU rounds will be held from 8:30 to 9:30 AM (Monday-Friday) and 7:30 to 8:30 AM (weekends and holidays). All CCU and elective CCU students are expected to be at each daily rounds session. Afternoon rounds will be held from 4:30 to 5:15 PM (week- days) and 3:00 to 3:30 PM (weekends and holidays). The purpose for afternoon rounds is to acquaint afterhours   students with the cases, to inform them of their specific responsibilities, and to assign the case to these students. Afterhours students are expected to complete all orders and record results. They will also be prepared to present the case to EM students at 10:00 PM each night.

Each student will keep a patient log of all their animals.  The log sheets are available in the rounds room.  At the end of the 3rd week, all patient logs will be returned to the CCU clinician.

7. CCU students will learn a number of monitoring procedures. These procedures will be taught by the nursing staff. Students will be expected to collect a central venous pressure, an electrocardiogram, set up fluid pumps, set up the central monitoring for ECG and temperature, and set up the oxygen cage. The minimum data base for all CCU patients will include body weight, TPR, packed cell volume, total solids (protein), urine specific gravity prior to fluid therapy, and a good glucose. CCU students should be sure there are adequate patient drugs to make it through until the morning or weekend.
 
8. Technical procedures such as intravenous catheterization, cystocentesis, activated clotting times, glucose monitoring, PCV, total solids, and other procedures will be practiced daily in CCU. All students will be expected to become proficient in these procedures. A videotape is available on the insertion and management of intravenous catheters. All students will review this tape prior to starting their CCU or EM rotations. The tape may be checked out from the CCU nurses. All CCU animals will have an emergency drug card calculated from the computer on entry into CCU. Generation of this card is the responsibility of the CCU student. To assure ourselves that each student has been given the opportunity to complete important procedures, a task sheet will be completed by each student and returned to the clinician following the last day of the three week rotation.
 
9. Several didactic topics will be covered each week. Specifically, the following schedule will provide guidance on the topic to be discussed each day.
Monday: Cardiopulmonary arrest and resuscitation
Tuesday: Shock and trauma
Wednesday: Fluid therapy and acidbase abnormalities
Thursday: Metabolic emergencies
Friday: Q & A (see below)
Veterinary Emergency Medicine Secrets will be used for student notes in this rotation. You are advised to read the appropriate sections prior to your rotation. All discussions will emanate from these sections. Discussions will be in a problem-based setting and not a lecture format. Discussions will be led by one of the CCU staff (clinician, resident, nurse).
Because CCU is a hospital service much like radiology, cardiology, anesthesia, etc, we cannot control our caseload. Occasionally we do not get to an assigned topic on the specific day. Before the week's end, most topics will be completed.
 
10. Grading in CCU will be the result of objective and subjective data collected by the CCU faculty, resident, and nursing staff. Involved personnel will provide input and assign a grade using the grade sheets for Critical Care and Emergency Medicine. Our philosophy states that on day 1 of CCU, all CCU students are superior veterinary students ("A" students). Your objective is to confirm our philosophy! Specific feedback will be related through the week. Students having difficulty with the rotation will be informed before Friday of the week.
 
11. CCU students will each chose a topic involving emergency medicine and write two important questions and the answers to those questions.  These questions will be given to the CCU clinician at the 4:30 PM rounds on Thursday of the rotation.  These questions will then be used in the Q & A session for Friday AM didactic rounds.   Ideally the questions will be on either topics not covered previously during the week or on topics not understood by the student. 

Critical care is an exciting, dynamic, new specialty in veterinary medicine. CSU students have the unique opportunity to work in a facility used by our profession as a model of excellence. We encourage your active participation and enthusiasm for this opportunity. It will be a demanding, sometimes stressful, rotation but will also be an opportunity to deal with acute illnesses often seen in everyday practice. We have a most elaborate facility but we also teach these technical procedures on a practical approach. We look forward to a most exciting week!

EMERGENCY MEDICINE AND AFTERHOURS

The emergency medicine rotation will provide all students the opportunity to apply their knowledge. There will be times when a veterinarian's support is not immediately available and thus you must act using your best judgement and knowledge. In order to encourage this action, CCU faculty are committed to supporting all actions of the EM students if these actions are written and recorded. It is important to remind all students that a doctor must be involved with all actions of the student. Always seek the advice of the intern/resident on duty, CCU nurse, CCU residents/faculty, or primary clinician before changing any treatments or monitoring procedures. Students will NEVER examine or admit a patient to the VTH without the permission and subsequent immediate physical presence of a doctor.

Emergency medicine students are expected to be on duty before 10:00 PM every night of the week (Sunday-Saturday). Any animal admitted to CCU after 4:00 PM or on weekends or holidays are to be presented in a rounds session by one of the EM students. If the case was admitted by the EM student all orders are to be written by the EM student. If another student has admitted the patient, EM students must see to it that the admitting student has written all orders and SOAPs for that case prior to rounds. If orders or SOAPs are not written by the admitting student, the EM student will be responsible for writing the orders prior to rounds!

Emergency medicine and afterhours students are responsible for didactic topics discussed in the critical care rotation.

Emergency medicine students are only responsible for QID treatments in the wards. Any animal not on the regular QID schedule will be treated by the student ordering the special treatment time. There will be NO EXCEPTIONS! Additionally, we would ask that one EM student walk through all small animal, zoo medicine, and junior surgery wards. If there is any doubt about a patient's well being, contact the clinician, CCU nurse, or the on-duty intern/resident. This walk-through should be done at least twice each night. Each morning the CCU staff will inquire about problems you have encountered in the wards. Occasionally a request for a QID treatment for a ward animal is made but no drugs have been left. EM students will NOT fill prescriptions! Call the student who failed to leave the medication.

Emergency medicine students will not be required to attend formal CCU rounds held at 8:30 AM on weekdays. AT 7:30 AM each weekday, the CCU clinician and one CCU nurse will be provided an update on cases by the EM students. This should only require 15 to 30 minutes. 

On weekends, EM students will attend 7:30 AM rounds with CCU students. They will be expected to present the cases to the CCU students. The format for presentation can be found in the description of the CCU rotation above. If the EM students admit an animal after hours, they are responsible for all paper work and treatments until the case is transferred to a CCU student (usually Monday at 8:30 AM).

CCU nursing staff will be available for assistance and EM coverage nightly. These nurses are extremely well qualified and talented in their skills. All students will find the experience of working with these talented persons a rewarding experience.

EM students are responsible for answering emergency phone calls coming to the VTH when the receptionists depart at 10:00 PM. Small animal emergencies come through on a phone located on the east wall (red tag) and emergencies for callers without touch tone phones will come through extension 241 on the west side of the room. Phone procedures are available at each phone. Additionally, if the phone rings beyond five rings, it will automatically go to a voice mail mode. In this way, the client can leave important information and all of these calls will be returned within 10 minutes of the original call. You will know there is a message if the green (red light on extension 112) message light is on. In order to obtain the message follow these procedures:

1. Dial 383
2. When asked to dial your extension, dial 112 (east phone) or 241 (west phone)
3. When asked to enter your password, dial 112 (east phone) or 241 (west phone)
4. Follow directions (press 2 to get the message, 0 to hear the message, and upon completion of the message and making appropriate notes, press *D to delete the message and thus turn off all message lights.

CCU will NEVER be left unattended! We must be available to answer the phone at all times. EM students will have a beeper that will be worn at all times.

Clients often want to visit their animal in CCU.  Visitations can only occur if arrangements have been made with the CCU faculty and staff PRIOR to the owner's visit.  It is best if we take the animal for a visit with the owner in an examination room. Too often CCU has a lot of activity and the client may be faced with witnessing CPR, admitting a seriously injured animal, or other unexpected catastrophe. Owners are to be informed that visiting hours will ONLY be from 9:30 AM to 9:00 PM. All visiting owners will be asked to leave by 9:00 PM (NO EXCEPTIONS!).

The VTH is a very large, often very quiet, facility in the middle of the night. BE CAREFUL! If at anytime you find a door propped open, close the door and be sure it is locked. If a door is unlocked, call the campus police immediately and have them come and lock the door. If you see someone in the hospital without proper ID, call the campus police immediately! Clients and strangers should not be in the hospital after hours. Your safety is a major concern! When a loud bell rings in CCU, it is probably a client at the front door. You may use the television and intercom system on the east wall to interrogate the person before going up front to open the door. If the person does not have an animal or does not in your judgement look like they have business in the VTH, do NOT open the door and immediately call the campus police!

Grading of students on the EM rotation is very subjective. Our procedure will be one of soliciting input from the CCU faculty, resident, and nurses. Specific comments will be forwarded to you.  Objective data will be collected from problem lists, task sheets, patient logs, flow sheets, and order sheets. Patient care and knowledge of CCU cases will be important in our assessment.

Upon completion of your CCU/EM rotations we encourage your feedback. There is a departmental evaluation form to be used. Go to Dr. Knight's office and request this form and return it to that office. If you prefer, you may write an evaluation and return it to the departmental office. Comments on faculty, staff, residents and the rotations can assist us in making this a better rotation.

Emergency medicine is an important practice opportunity for the new graduate. It provides one a lot of experience in a short period of time. Acute illnesses or injury to animals provides the veterinarian much personal satisfaction in being able to assist in a time of need. This rotation is designed to encourage your consideration of this practice opportunity.

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For more information please contact Wayne E. Wingfield

Revised:  05/13/99