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FACULTY OF INTENSIVE CARE

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					                       Joint Faculty of Intensive Care Medicine
                                                                     The Royal Australasian
Australian and New
                                                                      College of Physicians
Zealand College of                                                       ACN 000 039 047
  Anaesthetists
 ABN 82 055 042 852




                          OBJECTIVES OF TRAINING

                                              IN

                                 INTENSIVE CARE


                              FOR THE DIPLOMA OF FELLOWSHIP OF THE
                            JOINT FACULTY OF INTENSIVE CARE MEDICINE,
                      AUSTRALIAN AND NEW ZEALAND COLLEGE OF ANAESTHETISTS
                                               AND
                           ROYAL AUSTRALASIAN COLLEGE OF PHYSICIANS




                                      SECOND EDITION, 1997
                                           Revision 2003




                                                                                1
NOTE ON REPRINTING


This document was originally published by the Faculty of Anaesthetists, Royal Australasian
College of Surgeons in 1984. It was revised and updated in 1997 by the Faculty of Intensive
Care, Australian and New Zealand College of Anaesthetists. The document was adopted by
the Joint Faculty of Intensive Care Medicine, Australian and New Zealand College of
Anaesthetists and Royal Australasian College of Physicians without minor title changes and
reprinted in 2003.




                                                                                              2
FOREWORD TO THE FIRST EDITION


In 1976 the Faculty of Anaesthetists of the Royal Australasian College of Surgeons
published a unique document entitled "Objectives of Training" to guide trainees, teachers
and examiners for its diploma. In the same year the Faculty approved regulations to establish
a training and examination system for Specialists in Intensive Care.

It was apparent that guidelines were required for those training and preparing for the
examinations for the Fellowship endorsed in Intensive Care. This was difficult because
Intensive Care was a young specialty which involved a number of established disciplines
where areas of expertise overlapped. To define those areas which should be included in
training and examinations required expert advice.

Associate Professor G.A. Harrison, who made a major contribution to the Objectives relating
to training in Anaesthesia, undertook the initial preparation and it is largely due to his
enthusiasm that this document has been produced. He obtained opinions from a wide range
of people. Smaller groups, whose contributions are acknowledged elsewhere, spent
considerable time and effort consolidating these opinions. The size and complexity of the
task of producing such a unique document which involved a large number of people is a
credit to all those who have contributed.

The Board has undertaken the publication in the belief that it will fulfil the same role in
training Intensive Care Unit specialists that the "Objectives of Training" for Anaesthesia
fulfils in the training of Specialist Anaesthetists.

All those who have contributed are to be congratulated on the successful completion of this
task and the Board thanks them for their generous efforts and commends the document to all
those involved in the training and examination of Intensive Care Unit specialists whether
trainees, teachers or examiners.




                                                                                W.M CROSBY
                                                                                       Dean




 FORWARD TO THE SECOND EDITION
                                                                                                3
It has been a timely challenge for the Faculty of Intensive Care to define more precisely for
its trainees the knowledge and attributes required both for successful completion of its
Training and Examination program and also for the effective, efficient and practice of
intensive care. Since the publication of the first edition of Objectives of Training in
Intensive Care in 1984, the specialty has become more sophisticated, the expectations of
and by trainees have increased and the Faculty of Intensive Care has been established as a
separate entity within the Australian and New Zealand College of Anaesthetists.

The Second Edition of Objectives of Training in Intensive Care differs greatly in its
approach and format. It encompasses all aspects of the specialty, from retrieval,
resuscitation and management of critical illness through to research, ethics, quality and
administration. It sets educational objectives and defines the abilities and qualities
required to achieve these goals. It is not a syllabus and does not attempt to include every
specific issue. Examples of disease processes, therapeutic interventions and technical skills
are provided and the educational principles espoused can then be adapted to all other facets
of the field.

Writing the Second Edition, which draws heavily on the Objectives of Training in
Anaesthesia published in 1991, proved to be a most demanding task The document
produced is testimony to the tireless efforts of the then Education Officer Dr F.H. Hawker
and Dr G.M. Clarke, immediate past Dean. It also reflects on the knowledge and generous
efforts of Drs N.T. Matthews, J. Tibballs and R.V. Trubuhovich and the wise counsel of
Professor G.A. Harrison. Many other Fellows of the Faculty have also provided valued
input.

It is the hope of the Board of Faculty that this document will be of value and guidance to
trainees as they pursue their personal development and that it will shape their future careers
in intensive care.




                                                                             A.W. DUNCAN
                                                                                     Dean




                                                                                                 4
ACKNOWLEDGEMENTS TO THE FIRST EDITION


The content of this document is based on material prepared initially by Associate Professor
G.A. Harrison. It was modified considerably by the Liaison-Education Committee of the
Australian and New Zealand Society of Intensive Care under the Chairmanship of Dr L.l.G.
Worthley. Members of that Committee were Dr J.F. Cade, Royal Australasian College of
Physicians, Dr G.M. Clarke, Faculty of Anaesthetists, Dr M.G. Loughead, Royal
Australasian College of Physicians, Dr R.C. Wright, Australian and New Zealand Intensive
Care Society and Associate Professor G.A. Harrison, Faculty of Anaesthetists.

Subsequently, the content was further modified by Professor A.B. Baker, Dr G.M. Clarke
and Associate Professor G.A. Harrison as a working party of the Faculty of Anaesthetists'
Combined Education/Examination Committee in Intensive Care. Dr J.B. Vonwiller, Dr
G.C. Mullins and Dr A.W. Duncan contributed to the section on paediatric intensive care.

Many Fellows of the Faculty kindly viewed later drafts and contributed helpful suggestions.
Dr W.M. Crosby, Dean of the Faculty and Professor M.J. Cousins, particularly provided
valuable input at this stage.




                                                                                              5
CONTENTS ................................................................................................................Page

Introduction..........................................................................................................................1

Summary of Important Points..............................................................................................3

Overall Aims in the Training of an Intensive Care Specialist .............................................4

The Objectives of Training in Intensive Care

    1.         The Approach to Acute Illness............................................................................5

    2.         System(s) Failure.................................................................................................9

    3.         Disease and Disease Processes - Medical, Surgical and Obstetric Conditions.13

    4.         Therapy..............................................................................................................17

    5.         Supportive Care of the Critically Ill Patient......................................................21

    6.         Monitoring, Measurement, Investigations and Interpretation of Data ..............25

    7.         Cardiopulmonary Resuscitation ........................................................................33

    8.         Transportation of Critically Ill Patients.............................................................35

    9.         Technical Skills .................................................................................................37

    10.        Paediatrics .........................................................................................................39

    11.        Ethics .................................................................................................................41

    12.        Administration and Quality Assurance .............................................................43

    13.        Research in Intensive Care ................................................................................45

    14.        Education...........................................................................................................50

    15.        Communication .................................................................................................53


Appendix 1
         Representative List of Medical, Surgical and Obstetric Conditions                                                           55

Appendix 2
        Representative List of Treatments Undertaken in the Intensive Care Unit                                                      59

Appendix 3
        Representative List of Procedures relevant to the Intensive Care Specialist                                                  61




                                                                                                                                            6
INTRODUCTION

There are three major components to the education of an individual who wishes to attain the status of
an Intensive Care Unit specialist through the training scheme of the Joint Faculty of Intensive Care
Medicine, Australian and New Zealand College of Anaesthetists and Royal Australasian College of
Physicians.

1.     Supervised training with clinical experience in Units approved by the Joint Faculty and
       satisfactory In-training assessment

2.     Self directed learning

3.     Assessment at the Primary and Fellowship Examinations

The undertaking of a Formal Project, the EMST course or similar courses, and periods of training in
anaesthesia and medicine provide additional essential knowledge, skills and moulds attitudes for a
well-trained Intensive Care Unit specialist.

Throughout vocational training, trainees and their teachers need to be able to assess the trainee's
progress and clinical competence. To satisfy this need, the "Objectives of Training in Intensive Care"
is an educational statement that has been prepared to define and foster clinical competence. It is not
meant to be read in a single sitting but it should be consulted frequently by trainees and their
teachers throughout training.

The concepts covered in this document apply to both adult and paediatric practice. Now that
separate endorsement in paediatric intensive care exists, a separate document may be produced in
due course covering specific objectives for paediatric intensive care.

The document defines the knowledge, skills and attitudes that an Intensive Care Unit specialist
should acquire during the training period, and be maintained and enhanced throughout professional
life. It is a statement of the minimal level of competency expected at the end of the formal training
period. It therefore includes many of the issues and topics that will be examined in the Fellowship
Examination in Intensive Care and is, to some extent, a syllabus. Nevertheless, the examples and
lists are representative rather than exclusive, and topics not mentioned in this document may be
examined. Within each competency it is understood that the trainee:

       a.          accumulates knowledge
       b.          learns how to apply the knowledge
       c.          shows how an action is performed, in the light of the applied knowledge
       d.          undertakes the action

Clinical experience in an appropriate learning environment forms the cornerstone for achieving these
ends. It reinforces the knowledge gained from other sources. It contributes to the development of
diagnostic, problem solving and technical skills and the acquisition of attitudes appropriate for a
specialist in intensive care. A thorough knowledge of the basic sciences and a broad based
understanding of general medicine, surgery and other related disciplines are important prerequisites
for specialist intensive care practice. The role of mentors is also essential in developing appropriate
skills and attitudes and often in placing issues and developments in an historical context.

As far as possible, intensive care practice should be based on the best available scientific evidence.
At all times, the practice of intensive care medicine should be in accordance with the highest ethical
standards, with the patient’s welfare being of paramount importance.

                                                                                                     1
                               EDUCATIONAL BACKGROUND TO

                 THE "OBJECTIVES OF TRAINING IN INTENSIVE CARE"



Learning objectives state the skills which a learner should acquire. A behavioural objective is a
precise description of the performance of which a student should be capable of after learning (see,
for example, Gronlund, N.E. Stating Behavioural Objectives for Classroom Instruction, Collier-
McMillan, London, 1970). The “Objectives of Training in Intensive Care” states what the trainee
should accomplish with respect to:

(a)    Knowledge (cognitive skills)

(b)    Practical ability (psychomotor skills)

(c )   Attitudes (affective skills)

In each of these skill areas or domains there are a number of identifiable categories which allow
learning objectives to be organised according to their complexity and structure; their definition and
description is thus organised as a taxonomy. The two most generally accepted taxonomies are those
in the cognitive and affective domains constructed by 'A committee of college and university
examiners' and published under the authorship of Bloom B.S. et al Taxonomy of Education
Objectives: Book 1 - Cognitive Domain, New York, David McKay, 1956 and Krathwohl D.R. et al
Taxonomy of Educational Objectives: Book 2 - Affective Domain, London, Longman, June 1964
respectively. The taxonomy developed by Bloom has been used in this document to describe the
educational terms used to introduce the various learning experiences.

Basic terms used in this document are:

General Instructional Objective

A General Instructional Objective is a broad statement of skills to be acquired by the trainee.

Perusal of these alone will present the general picture of the objectives of training.


Required Abilities and Qualities

These are specific behavioural objectives. They give examples of abilities and qualities which
indicate that the General Instructional Objective has been achieved. The development of additional
abilities and qualities should be encouraged.




                                                                                                   2
                     3




 FUNCTION OF THE OBJECTIVES

                  TRAINEE




          OBJECTIVES OF TRAINING




KNOWLEDGE           SKILLS         ATTITUDES




    GENERAL INSTRUCTIONAL OBJECTIVES




            LEARNING EXPERIENCES




 ACQUIRES REQUIRED ABILITIES AND QUALITIES




ACHIEVES GENERAL INSTRUCTIONAL OBJECTIVES




     ACHIEVES OBJECTIVES OF TRAINING




            AWARDED FELLOWSHIP



       MAINTENANCE OF COMPETENCE
                                                   4




OVERALL AIMS IN THE TRAINING OF AN INTENSIVE CARE SPECIALIST

These aims define the attributes of an Intensive Care Unit specialist as a practitioner in a specialty, a
member of a health care team, and as an individual involved in self education and the education of
others. They outline those qualities of an Intensive Care Unit specialist which are important in the
management of patients and in relationships with other practitioners of medicine, members of the
health care team and the community.

During their formal period of training, trainees should:

1.     Acquire such knowledge, problem solving ability, practical skills and attitudes appropriate
       for the safe and effective practice of intensive care. This extends to patients, equipment and
       the intensive care environment.

2.     Develop the ability to respond rapidly and appropriately to life threatening problems and
       establish the priorities of management.

3.     Become safe and competent Intensive Care Unit specialists such that they are able, as
       appropriate, to conduct the overall management of a patient, to act as a consultant or co-
       ordinate management involving a number of consultants.

4.     Be able to act appropriately as a member or leader of a team.

5.     Acquire knowledge in those aspects of medicine, surgery, paediatrics, obstetrics,
       anaesthesia and other disciplines which are relevant to the practice of an Intensive Care
       Unit specialist.

6.     Develop the ethic that the patient's welfare always takes precedence in the event of medical,
       political or ethical conflicts.

7.     Provide patients with the best possible care considering available resources.

8.     Learn to identify and modify the stresses which the intensive care environment places upon
       the patients, their relatives and hospital staff.

9.     Participate in the processes of clinical audit and quality improvement activities.

10.    Enquire into clinical and scientific problems, adopting systematic and critical appraisal of
       available information.

11.    Contribute to the education of medical, nursing and paramedical staff.

12.    Seek to recognise those changes in their specialty, medicine or society which require
       modification of their practice.

13.    Develop a process of regular self-assessment so that limitations can be identified and
       deficiencies relevant to intensive care practice corrected.

14.    Be aware of current Joint Faculty and College policies on professional issues and act in
       ways consistent with these policies.
                                                5




ONE        THE APPROACH TO ACUTE ILLNESS


1.1   Introduction

      Intensive Care Unit specialists require an extensive knowledge of medical and surgical
      conditions and mastery of practical skills. These attributes form part of the complex process
      of clinical problem solving and decision making. The Intensive Care Unit specialist
      anticipates clinical problems. He/she is able to assess and define clinical problems in the
      critically ill in the broader context and can develop and facilitate a diagnostic and
      management plan which has the highest probability of a satisfactory outcome.

      A model of the approach of the Intensive Care Unit specialists to acute illness is shown
      below. The steps within each stage often overlap considerably.

1.2   Immediate Assessment and Therapy (Resuscitation)

      General Instructional Objective

      Is able to make a quick and accurate assessment of the life threatening problems in a
      critically ill patient and apply life supporting therapy.

      Required Abilities and Qualities

      a.              Judges whom to resuscitate (and whom not to)
      b.      Judges the priorities of immediate resuscitation versus diagnosis and treatment of
              the primary disease process
      c.      Undertakes emergency management including basic and advanced life support (see
              Section 7), including management of the difficult airway
      d.      Obtains relevant information rapidly and accurately and performs a brief, pertinent
              examination enabling immediate and effective resuscitation to be achieved including
              the management of rapidly reversible problems eg. tension pneumothorax
      e.      Instigates routine investigations during the course of resuscitation to exclude other
              rapidly reversible problems eg. hyperkalaemia
      f.      Obtains an accurate history (if this was not possible previously) and performs a
              clinical examination as soon as possible to detect the primary disease process
      g.      Monitors vital physiological functions whilst further assessment is undertaken
      h.      Recognises and responds rapidly to adverse trends in monitored parameters

1.3   Formal Medical Assessment, Problem Solving and Decision Making

      General Instructional Objective

      Following resuscitation, effectively undertakes or contributes to the continuing management
      of the acutely ill patient.

      Required Abilities and Qualities

      1.3.1   Assessment

              a.     Obtains all relevant information from the patient, relatives and other
                     informed sources
                                                  6



                b.     Takes and records an accurate and thorough medical history (with relevant
                       family, past, social, and occupational history)
                c.     Performs a thorough physical examination
                d.     Recognises and diagnoses a system failure, a disease, a pathological process,
                       a clinical syndrome or a complication of therapy
                e.     Orders appropriate investigations and interprets the results correctly to assist
                       diagnosis, monitoring and assessment of therapy

        1.3.2   Problem Definition

                a.     Documents patient information either in a chronological or system or
                       problem oriented format, allowing a clear presentation of the problems and
                       progress
                b.     Generates an appropriate list of differential diagnoses and prioritises
                       investigations
                c.     In emergency situations, confirms or refutes some early diagnoses before
                       data collection is complete, and deals with the ambiguity and uncertainty that
                       would otherwise result. Based on these diagnoses, make contingency plans
                       to combat further threats to the patient's life
                d.     Chooses, if possible, the most probable diagnosis and redefines the patient's
                       problems in the light of this choice, while remaining alert to the possible
                       presence of less likely diagnoses which may have life-threatening
                       consequences.

        1.3.3   Generation of Solutions to the Patient's Problem

                Assembles facts, logically compares all potential solutions to the patient's problems,
                and assigns weight and priorities to them.

        1.3.4   Decision Making

                a.     Chooses the optimal course of action
                b.     Decides if there are elements of the patient's problem which are not dealt
                       with by the selected course of action and develops appropriate solutions for
                       those elements.

        1.3.5   Planning

                a.     Proposes a therapeutic plan which incorporates the selected courses of action
                       and takes note of potential interactions of elements of the plan (eg. what will
                       happen if a particular therapy is used or not, when and how will it act, are
                       there interactions with other therapies or interventions)
                b.     Plans counter measures to potential complications of the disease or therapy
                c.     Applies appropriate scoring systems to assess the likely outcome
                d.     Defines the medical and ethical circumstances in which supportive therapy
                       should be limited or discontinued
                e.     Considers risk benefit and cost benefit of therapeutic alternatives in
                       developing a plan.

1.3.6   Progress

        a.      Understands the requirement to assess the patient's progress often and to modify
                diagnosis and therapy when necessary
        b.             Develops criteria for discharge from the Intensive Care Unit
                                                7



      c.             Assesses the value of intensive care by follow-up after discharge
      d.             Counsels patients and relatives

1.4   Consultation and Collaboration

      General Instructional Objective

      Consults and collaborates effectively during the management of critically ill patients.

      Required Abilities and Qualities

      a.             Understands that consultation and collaboration play a vital role in the
             management of the critically ill patient
      b.             Acquires a wide knowledge of disease states (all sections) to enable
             recognition of the need to consult
      c.     Recognises his/her limitations to providing optimal patient care
      d.     Knows how, when and who to ask for a second opinion
      e.     Recognises his/her limitations as a consultant to other specialists
      f.     Keeps referring specialists informed of the patient's progress and encourages their
             participation in decision making

1.5   Assessment of Illness and Injury Severity and Outcome Prediction

      General Instructional Objective

      Understands the clinical and physiological markers used to assess illness and injury severity
      and the scoring systems developed for assessing the likely outcome from acute illness.

      Required Abilities and Qualities

      a.     Appreciates clinical severity of illness and when organ dysfunctions or failure are an
             immediate threat to life
      b.     Knows that sudden gross changes in certain physiological parameters are life
             threatening (eg. mean arterial pressure, pH, PaO2, plasma potassium concentration)
      c.     Understands the various scoring systems and their usefulness in assessing likely
             outcome of an illness (eg. Glasgow Coma Scale, APACHE II and III, PRISM, organ
             system failure scores, injury severity scores)
      d.     Understands that the validity of a scoring system as a predictor of likely outcome
             may be influenced by the injury or illness being considered (eg. Glasgow Coma
             Score (GCS) in head injury versus drug overdose)
      e.     Understands the limitations of scoring systems in general in predicting individual
             patient outcome




TWO        SYSTEM(S) FAILURE
2.1   Introduction
                                                8



      Patients with individual and multiple systems organ failure (MSOF) form a major part of
      the workload of an Intensive Care Unit. System(s) failure may be the result of a local cause
      or disease process, or be related to a systemic disease or process. Failure of one system may
      adversely affect the function of other systems, although in most cases of multiple systems
      failure, there is an underlying systemic cause (eg. an uncontrolled generalised inflammatory
      response secondary to sepsis or other insult).

2.2   Management of System(s) Failure

      General Instructional Objective

      Knows how to manage a patient with a single or multiple systems failure.

      Required Abilities and Qualities

      a.      Recognises a specific organ failure and assesses its severity
      b.      Understands the underlying causes of system(s) failure and the importance of
              preventing and treating these quickly and definitively
      c.      Understands current concepts of the pathophysiological pathways and mechanisms
              involved and the evidence for and against interruption of such pathways as a means
              of treatment
      d.      Provides optimal treatment for any type of system failure
      e.      Adopts a balanced approach to the patient with multiple system failure so that the
              aggressive management of one system is not to the detriment of other systems unless
              this course of action is necessary for the immediate survival of the patient
      f.      Knows commonly used definitions of organ failure and scoring systems based on
              these
      g.      Understands the prognostic implications of multiple systems failure or multiple
              organ dysfunction syndrome (MODS)

2.3   Examples

      2.3.1   Acute Circulatory Failure

      General Instructional Objective

      Undertakes the management of a patient with a shock syndrome.

      Required Abilities and Qualities

      a.      Defines and recognises shock and assesses its severity
      b.      Knows the causes of shock and how they are identified and treated
      c.      Knows the steps involved in reversing shock according to its aetiology and in
              response to haemodynamic and other physiological data
      d.      Understands current concepts of the pathogenesis of shock and the potential
              therapies that may result from interruption of inflammatory mediator and other
              pathways
      e.      Knows the importance and limitations of non-invasive and invasive monitoring in
              the management of such patients
      f.      Knows the sequelae of shock and their prevention and management
      g.      Knows the principles of outcome prediction in shock states.

      2.3.2   Respiratory Failure
                                                 9



        General Instructional Objective

        Undertakes the management of a patient with respiratory failure.

        Required Abilities and Qualities

        a.      Defines and recognises respiratory failure and assesses its severity
        b.      Knows the causes of respiratory failures and how these may be prevented or
                managed
        c.      Can distinguish acute from chronic respiratory failure and understands the
                implications for management
        d.      Understands concepts of pathogenesis of acute lung injury and the potential for
                interruption of inflammatory mediator and other pathways as methods of treatment
        e.      Understands the principles of oxygen therapy and mechanical methods of
                ventilatory support (invasive and non-invasive)
        f.      Understands the effects of disease processes and treatments on other organ systems
        g.      Knows the complications of the disease processes and the treatments used and
                proposes a management plan to prevent and manage them
        i.      Understands principles of outcome prediction in patients with respiratory failure

        2.3.3   Renal failure

        General Instructional Objective

        Undertakes the management of a patient with renal failure.

        Required Abilities and Qualities

        a.      Defines and recognises renal failure and assesses its severity
        b.      Knows the causes of renal failure and how these may be prevented and managed
        c.      Can distinguish acute from chronic forms of renal failure and understands the
                different clinical courses
        d.      Understands concepts of the pathogenetic mechanisms of acute renal failure
        e.      Can identify patients at risk of developing renal failure, knows the therapies that
                may have prophylactic benefits, and understands the indications for their use
        f.      Understands the complications of renal failure and proposes a plan of prevention or
                treatment
        g.      Understands the various forms of renal replacement therapy and their indications
                and applications and uses them effectively
        h.      Understands the effects of renal failure and its treatment on other organ systems
        i.              Understands the principles of outcome prediction in patients with renal
                failure


2.3.4   Neurological Failure

        General Instructional Objective

Undertakes the management of an unconscious patient.

        Required Abilities and Qualities

        a.      Defines and recognises coma and assesses its severity
        b.      Knows the causes of coma and how they are identified and treated
                                              10



       c.     Knows the indications for neurosurgical consultation
       d.     Knows the indications for urgent imaging of the brain and understands the
              requirements for safe performance of the procedure
       e.     Understands the pathogenesis, causes and treatment of cerebral swelling and raised
              intracranial pressure
       f.     Knows the indications for monitoring intracranial pressure, jugular venous bulb
              oxygen saturation and other relevant parameters, and their limitations
       g.     Understands the importance of cerebral perfusion pressure, cerebral oxygenation
              and the methods by which they may be optimised
       h.     Understands the effects of coma and its support and treatment on other organ
              systems
       i.             Understands the principles of outcome prediction in patients with coma



Similar principles should be applied to failure of other organs and systems
                                                 11




THREE DISEASE AND DISEASE PROCESSES
    - MEDICAL, SURGICAL AND OBSTETRIC CONDITIONS

        3.1    Introduction
        The Intensive Care Unit specialist may be required to treat patients with a wide range of
        primary or complicating medical, surgical and obstetric conditions.

        General Instructional Objective

        Has a broad knowledge of medical, surgical and obstetric conditions together with a
        detailed knowledge of those that may be life-threatening.

        Required Abilities and Qualities

        a.     Diagnoses and manages those conditions which are recognised to be within the
               domain of the Intensive Care Unit specialist
        b.     Diagnoses and manages other acute conditions until the appropriate specialist
               assistance is available
        c.     Recognises the need for operative intervention and consults
               appropriately
        d.     Recognises the complications of common operations and consults appropriately
        e.     Understands the effect of chronic disease processes (and their management)
               on the management and course of acute diseases

        A representative list of the common medical, surgical and obstetric conditions likely to be
        encountered by trainees is given in Appendix 1. This does not constitute an exhaustive
        syllabus, but is presented to demonstrate the potential breadth of knowledge required.

3.2     Examples

3.2.1   Ischaemic Heart Disease and Myocardial Infarction

        General Instructional Objective

        Knows how to manage patients with ischaemic heart disease and acute myocardial
        infarction.

        Required Abilities and Qualities

        a.     Understands the factors involved in the balance of oxygen supply and demand to the
               heart
        b.     Understands the aetiology of coronary artery disease and its effects
        c.     Knows and recognises the signs and symptoms of ischaemic heart disease
        d.     Knows and recognises the signs and symptoms of myocardial infarction, its
               pathogenesis, the differential diagnosis and diagnostic criteria
        e.     Describes the acute management of myocardial infarction including thrombolysis,
               and the indications and contraindications for thrombolysis, angioplasty and surgical
               intervention
                                                  12



        f.       Knows the indications for the insertion of a transvenous pace-maker, right heart
                 catheterisation, angiography, echocardiography, radionucleotide imaging of the
                 heart and other procedures and investigations
        g.       Recognises the complications of myocardial infarction and the need for medical and
                 surgical intervention
        h.       Knows the principles of postoperative cardiac surgical care and undertakes it
                 effectively
        i.       Understands the long term effects of acute myocardial infarction and recognises late
                 complications
        j.       Understands the management of ischaemic heart disease in patients undergoing
                 anaesthesia and surgery, and in patients with concurrent illness.

3.2.2   Severe Trauma

        General Instructional Objective

        Undertakes the management of patients who have suffered severe trauma.

        Required Abilities and Qualities

        a.                Understands the effects of severe trauma on organs and organ systems
        b.                Appreciates the principles of the EMST system for the management of the
                 critically injured and the advantages of an organised team approach
        c.                Can function as a team leader
        d.                Uses a systematic approach to the resuscitation, assessment, investigation
                 and emergency management of a critically injured patient
        e.                Prioritises life-threatening injuries requiring immediate intervention,
                 including urgent surgical management
        f.                Prioritises the order of investigations for individual injuries according to
                 their threat to life
        g.                Undertakes those appropriate investigations in a safe and timely
                 manner
        h.                Recognises those aspects in which the management of the injured
                 child is different from that of the adult
        i.                Determines when the patient’s needs exceed local capacity and
                 arranges safe transfer
        j.       Undertakes the continuing management of the patient including the
                 prevention, recognition and management of complications
        k.       Understands the principles of injury severity scoring systems and
                 their relationship to outcome

3.2.3   Sepsis

        General Instructional Objective

        Undertakes the management of a patient with sepsis.


        Required Abilities and Qualities

        a.       Defines sepsis and related syndromes and applies these definitions to diagnosis
        b.       Understands concepts of the pathogenesis of sepsis and related syndromes
        c.       Undertakes the resuscitation of a patient with septic shock using appropriate
                 monitoring, fluid therapy and vasoactive agents
                                     13



d.   Takes appropriate specimens for laboratory examination
e.   Prescribes appropriate antimicrobial therapy based on the history, examination and
     preliminary investigations
f.   Recognises the need for surgical intervention to treat the underlying cause and
     consults appropriately
g.   Recognises the multisystem effects of sepsis and instigates appropriate supportive
     therapy including nutritional therapy
h.   Understands the scientific basis of therapy based on modulation of inflammatory
     mediators and recognises its limitations
i.   Knows the risk factors for nosocomial infection and uses appropriate infection
     control measures to limit its occurrence
                                                 14




FOUR         THERAPY
4.1   Introduction

      Intensive care management involves therapy to reverse life-threatening physiological
      derangements as well as specific treatment of the underlying disease. The Intensive Care
      Unit specialist must have an extensive knowledge of therapies commonly undertaken in the
      Intensive Care Unit, and their complications. These include pharmacological treatments eg.
      inotropes, surgical treatments, mechanical treatments eg. mechanical ventilation and other
      treatments eg. physiotherapy

      General Instructional Objective

      Undertakes appropriate treatment to correct physiological derangements and to treat
      specific diseases.

      Required Abilities and Qualities

      a.     Knows the range of treatments available for a specific physiological derangement or
             disease
      b.     Understands when treatment is unnecessary
      c.     Critically appraises the evidence for and against particular treatments
      d.     Knows the indications and contraindications for a particular treatment
      e.     Appreciates the likely success rate and the limitations of an individual treatment for
             a specific condition
      f.     Knows the complications of particular therapies and their incidence and
             management
      g.     Understands the effects of concomitant treatment and/or co-morbid conditions on an
             individual patient’s response to treatment
      h.     Prioritises therapy according to patient need
      i.     Understands the concept of risk:benefit ratio of a therapy and can apply this concept
             to a particular patient
      j.     Understands the concept of cost:effectiveness of a therapy and the value of a
             specific treatment to both the individual and the community
      k.     Recognises when treatment is futile
      l.     Formulates a plan of management for an individual patient
      m.     Reviews the efficacy of the chosen treatment at regular intervals
      n.     Institutes alternative therapies according to patient need
      o.     Reviews outcomes of specific therapies

4.2   Examples4.2.1         Fluid Therapy
      General Instructional Objective

      Prescribes and institutes appropriate fluid management for a critically ill patient.

      Required Abilities and Qualities

      a.    Knows the causes and pathophysiological effects of altered intravascular volume and
            state of hydration
      b.    Knows how to assess the intravascular volume status and state of hydration of a
            patient using clinical signs and monitoring
      c.    Knows the components, physical properties, and behaviour of fluids commonly used
            in therapy
                                           15



d.      Knows the indications, contraindications and complications of various fluid therapies
        and their administration
e.      Knows the theoretical advantages and disadvantages of crystalloid and colloid
        solutions
f.      Understands the principles of blood and blood component therapy
g.      Sets goals for fluid therapy
h.      Chooses the appropriate fluid, volume and rate of administration of fluid
i.      Reviews regularly the efficacy of fluid therapy
j.      Considers and excludes unknown pathology (eg. continued bleeding) if goals are not
        achieved
k.      Institutes an alternative fluid regimen if goals are not achieved
l.      Institutes alternative non-fluid therapy (eg. inotropic therapy) if goals are not
        achieved

4.2.2   Inotropic Therapy

General Instructional Objective

Institutes and maintains appropriate inotropic therapy for a critically ill patient.

Required Abilities and Capabilities

a.      Knows the physiology and anatomical distribution of adrenergic and other relevant
        receptors
b.      Understands the effects of critical illness and concomitant therapies on receptor
        function (eg. down-regulation)
c.      Knows the effects of relevant inotropic and vasopressor agents on specific receptor
        populations
d.      Can recognise the need for inotropic or vasopressor therapy
e.      Characterises the haemodynamic derangement using clinical examination and
        invasive haemodynamic monitoring
f.      Sets goals for inotrope/vasopressor therapy
g.      Chooses the appropriate inotrope/vasopressor for the individual patient
h.      Chooses an appropriate dose, physiological endpoint, rate and route of
        administration of the selected inotrope/vasopressor
i.      Knows the potential adverse effects and complications of inotropic therapy in
        general and of individual medications
j.      Knows the interactions among inotropic agents and concomitant therapies and with
        co-morbid disease (eg. ischaemic heart disease)
k.      Reviews the efficacy of inotropic therapy at regular intervals
l.      Considers and excludes unknown pathology (eg. sepsis) if goals are not achieved
m.      Institutes an alternative inotropic regimen if goals are not achieved
n.      Understands the limitations of inotropic therapy
o.      Institutes alternative therapy (eg. balloon counterpulsation) if goals are not achieved

4.2.3   Respiratory Therapy

General Instructional Objective

Uses respiratory therapy effectively.

Required Abilities and Capabilities
                                         16



a.     Has a sound knowledge of respiratory physiology and understands the effects of
       pulmonary pathology on physiological parameters
b.     Can recognise respiratory failure and knows when intervention is necessary
c.             Knows how to secure the airway safely and effectively, including the
       difficult airway
d.             Knows the complications of endotracheal intubation and takes steps to
       minimise these
e.             Understands the principles of oxygen therapy and oxygen delivery systems
f.     Understands the principles of continuous positive airways pressure (CPAP) and
       positive end-expiratory pressure (PEEP) and CPAP and PEEP delivery systems
g.     Understands the principles of mechanical ventilation and mechanical ventilators
h.     Understands the principles of the different modes of mechanical ventilation
i.     Chooses the appropriate type and mode of respiratory support for an individual
       patient
j.     Knows the potential adverse effects and complications of the various types and
       modes of respiratory support and takes steps to minimise these
k.     Sets goals for respiratory therapy
l.     Reviews the efficacy of therapy at regular intervals
l.     Considers and excludes problems (eg. tube in right main bronchus, tension
       pneumothorax) if goals are not achieved
m.     Institutes alternative respiratory therapy if goals are not achieved
n.     Institutes alternative non-respiratory therapy if goals are not achieved

Similar principles should be applied to other treatments used in the ICU.

A representative but not exhaustive list is shown in Appendix 2.
                                                   17




FIVE           SUPPORTIVE CARE OF
               THE CRITICALLY ILL PATIENT
5.1     Introduction

        Although prompt and definitive resuscitation, assessment, diagnosis and specific therapy
        are crucial to the successful management of critically ill patients, longer term support is
        often required while injured tissues and organs heal and while the physiological
        consequences of illness and injury are normalised. The concept of total patient care is
        central to the discipline of intensive care medicine. This includes the support of the function
        of all organs, measures to prevent complications, and alleviation of pain, anxiety and
        psychosocial distress. According to need this social support should extend to the immediate
        family.

5.2     Support of the Function of Organs

        General Instructional Objectives

        Understands that support of all organ systems is vital to the care of critically ill patients
        irrespective of the organ or system primarily affected by the presenting illness. Undertakes
        or contributes to the overall supportive management of the acutely ill patient.

        Required Abilities and Qualities

        a.     Understands the regulatory processes controlling the function of the particular organ
               or system
        b.     Understands how critical illness may affect these homeostatic mechanisms
        c.     Recognises disorders of function of the particular organ or system
        d.     Knows the consequences of abnormal function of the particular organ or system
        e.     Institutes appropriate treatment for abnormal function of the particular organ or
               system
        f.     Proposes an appropriate supportive regimen for an individual patient

5.2.1   Examples

5.2.1.1 Nutritional Support

        General Instructional Objective

        Provides appropriate nutritional support for an acutely ill patient.

        Required Abilities and Qualities

        a.     Understands the metabolic response to critical illness and starvation
        b.     Assesses the nutritional requirements of critically ill patients
        c.     Appreciates the adverse consequences of malnutrition
        d.     Knows how to monitor nutritional status
        e.     Knows the advantages and disadvantages of different nutritional formulations and
               different routes of administration
        f.     Institutes an appropriate nutritional regimen for an individual critically ill patient

5.2.1.2 Metabolic support
                                                  18




        General Instructional Objective

        Achieves and maintains normal fluid, electrolyte and glucose balance in a critically ill
        patient.

        Required Abilities and Qualities

        a.     Understands the normal processes controlling fluid, electrolyte, acid-base and
               glucose balance
        b.     Can recognise disorders of fluid, electrolyte, acid-base and glucose balance
        c.     Appreciates the pathophysiological consequences of disordered fluid, electrolyte,
               acid-base and glucose balance
        d.     Knows how to treat abnormalities of fluid, electrolyte, acid-base and glucose
               balance
        e.     Institutes an appropriate fluid and electrolyte regimen for an individual critically ill
               patient

5.2.1.3 General Care

        General Instructional Objective

        Institutes an appropriate plan for care of bowels, skin, mouth, eyes and maintenance of
        mobility and muscle strength in critically ill patients.

5.3     Prevention of Complications

        General Instructional Objectives

        Recognises that complications of Intensive Care Unit management can contribute to
        morbidity and mortality, audits their occurrence and proposes measures to reduce their
        incidence and severity.

        Required Abilities and Qualities

        a.     Knows the risk that a particular complication may develop and the predisposing
               factors
        b.     Modifies treatment to minimise the risk
        c.     Monitors appropriate parameters to allow early detection if the complication cannot
               be avoided
        d.     Knows how to treat the particular complication

5.3.1   Examples

5.3.1.1 Nosocomial Infection

        a.     Understands the risk of colonisation with potentially pathogenic micro-organisms,
               and the factors associated with patient, staff, equipment and environmental
               colonisation
        b.     Describes and implements infection control procedures relevant to the ICU
        c.     Understands the importance of culturing body fluids and the principles of their
               collection
        c.     Recognises the difference between colonisation and invasive infection
                                               19



       d.     Proposes and implements a plan for care of intravascular catheters and other
              invasive devices
       e.     Describes an antibiotic policy for the ICU
       f.     Efficiently manages an individual patient with nosocomial infection

5.3.1.2 Ventilator-Associated Lung Injury

       a.     Understands the pathogenesis and risk factors for ventilator-associated lung injury
       b.     Recognises the potential complications of different forms of ventilation
       c.     Describes the manifestations of pulmonary barotrauma
       d.     Describes the manifestations of pulmonary oxygen toxicity
       e.     Proposes and implements a treatment plan for an individual patient with severe
              pulmonary barotrauma
       f.     Appreciates that lung injury in ventilated patients may result from other causes eg.
              suction, inadequate humidification, thermal injury etc

5.3.1.3 Thromboembolic Disease

        a.             Understands the pathogenesis and risk factors for venous, arterial and
              intracardiac thrombosis and embolism
        b.             Considers the benefits and risks of different prophylactic regimens
        c.             Recognises the signs and symptoms of thromboembolism and knows how to
              confirm the diagnosis
        d.             Proposes and implements treatment plans for intravascular thrombosis,
              pulmonary and systemic embolism

5.3.1.4 Stress Ulceration

       a.     Recognises the pathogenesis and risk factors for stress ulceration
       b.     Considers the benefits and risks of different prophylactic regimens and effectively
              institutes them
       c.     Proposes a therapeutic plan for gastrointestinal bleeding

5.4    Allevation of Pain and Suffering

       General Instructional Objective

       Recognises the duty to alleviate pain, anxiety and psychosocial distress and is able to
       undertake or contribute to a plan of treatment to achieve this end.

       Required Abilities and Qualities

       a.     Understands the physiological effects of pain and anxiety
       b.     Anticipates the development of pain and/or anxiety and adopts strategies for its
              prevention or minimisation
       c.     Knows how to recognise and assess the degree of pain and/or anxiety
       d.     Understands the effects of analgesic, sedative and hypnotic drugs and their uses and
              complications
       e.     Describes regional anaesthetic techniques, and their indications and complications
       f.     Proposes and implements a plan to prevent and manage pain, anxiety and
              psychosocial distress depending on individual need
       g.     Proposes and implements a plan to provide adequate rest and sleep in Intensive Care
              Unit patients
                                                  20




SIX        MONITORING, MEASUREMENT,
         INVESTIGATIONS AND INTERPRETATION OF DATA
6.1     Introduction

        The Intensive Care Unit specialist requires a broad knowledge of monitoring, measurement,
        investigations and the interpretation of data. This includes an understanding of the
        indications, limitations and complications of techniques involved and proficiency in the
        relevant technical skills where these fall within the ambit of the Intensive Care Unit
        specialist (see Chapter 9 Technical Skills).

6.2     Principles of Measurement

        General Instructional Objective

        Understands the principles of measurement as applied to the critically ill patient and can use
        relevant methods effectively.

        Required Abilities and Qualities

        a.     Knows when to monitor, measure or investigate
        b.     Understands the principles of the system used
        c.     Understands the risk/benefit ratio of the modality chosen
        d.     Identifies deviations from normal range
        e.     Understands how trend of change may be significant
        f.     Identifies changes which are life threatening and responds accordingly
        g.     Recognises artefact and/or errors
        h.             Knows when to intervene
        i.             Responds appropriately

6.3     Bedside Monitoring

6.3.1   Continuous ECG monitoring

        General Instructional Objective

        Understands the principles of ECG monitoring, its relevance to clinical practice and uses it
        effectively.

        Required Abilities and Qualities

        a.     Knows that information relating to heart rate, rhythm, conduction, ST segment
               change and QT interval may be obtained
        b.     Understands advantages and disadvantages of different lead configurations
        c.     Knows the indications for ECG monitoring
        d.     Knows the limitations for ECG monitoring
        e.     Recognises change which is potentially life threatening
        f.     Sets alarms appropriately
        g.     Differentiates real change from artefact
        h.             Responds appropriately

6.3.2   Invasive pressure monitoring
                                                  21




        General Instructional Objective

        Understands the principles of invasive pressure monitoring, its relevance to clinical practice
        and uses it effectively.

        Required Abilities and Qualities

        a.     Knows the functions of the components of an electromanometer system (catheter,
               tubing, transducer, amplifier and display unit)
        b.     Knows correct zero and calibration techniques
        c.     Understands the principles involved in optimising the dynamic response
               characteristics of the catheter-tubing-transducer set up and how the natural
               frequency and damping coefficient determines the dynamics of the system
        d.     Knows the indications for invasive pressure monitoring
        e.     Knows the limitations of invasive pressure monitoring
        f.     Understands the risk/benefit ratio
        g.     Recognises change which is potentially life threatening
        h.     Sets alarms appropriately
        i.     Differentiates real change from artefact
        j.     Responds appropriately

6.3.3   Pulse oximetry

        General Instructional Objective

        Understands the principles of pulse oximetry, its relevance to clinical practice and uses it
        effectively.

        Required Abilities and Qualities

        a.    Understands the physical principles of pulse oximetry
        b.    Knows the indications for pulse oximetry
        c.    Knows the limitations of pulse oximetry and the causes of erroneous readings
        d.    Recognises change which is potentially life threatening
        e.    Sets alarms appropriately
        f.    Differentiates real change from artefact
        g.            Responds appropriately

6.3.4   Monitoring of ventilation

        General Instructional Objective

        Understands the principles of monitoring of ventilation, its relevance to clinical practice and
        uses it effectively.

        Required Abilities and Qualities

        a.     Knows the significance of respiratory rate, tidal and minute volume; mean, peak,
               end inspiratory and plateau pressure and end expiratory pressure (intrinsic and
               extrinsic); inspired oxygen concentration; arterial blood gas and acid base status
        b.     Knows the effect of ventilation upon cardiovascular and oxygen delivery
               parameters, other organ function and how these effects can be monitored
                                                22



        c.     Understands how the mode of ventilation may influence the choice of parameters
               monitored and the effects on these parameters
        d.     Knows the hazards of inadequate monitoring including lack or misuse of alarm
               settings
        e.     Understands the mechanisms, effects and clinical manifestations of barotrauma and
               how monitoring may provide early evidence of the likelihood or occurrence of this
               complication
        f.             Responds appropriately

6.3.5   End tidal CO2 monitoring

        General Instructional Objective

        Understands the principles of end tidal CO2 monitoring, its relevance to clinical practice
        and uses it effectively.

        Required Abilities and Qualities

        a.     Understands the physical principles involved in end tidal CO2 monitoring
        b.     Knows the relationship of end tidal CO2 and arterial PCO2 in various clinical
               circumstances
        c.     Knows the indications for end tidal CO2 monitoring
        d.     Knows the limitations of end tidal CO2 monitoring
        e.     Sets alarms appropriately
        f.     Responds appropriately

6.3.6 Invasive haemodynamic monitoring using a pulmonary artery catheter

        General Instructional Objective

        Understands the principles of invasive haemodynamic monitoring using a pulmonary artery
        catheter, its relevance to clinical practice and uses it effectively.

        Required Abilities and Qualities

        a.     Understands the significance of and the relationships between central venous
               pressure, mean pulmonary artery pressure, pulmonary artery diastolic pressure,
               pulmonary artery wedge pressure, mean systemic arterial pressure, cardiac output
               and how relationships may change in various clinical circumstances (eg. cardiac
               tamponade, hypovolaemic shock)
        b.     Knows how to derive additional indices such as cardiac index, systemic and
               pulmonary vascular resistance (index), left and right stroke work index, oxygen
               extraction ratio, oxygen delivery and consumption
        c.     Understands basic functional principles of an electromanometer system and
               measurement of cardiac output by thermodilution
        d.     Knows the indications for the use of pulmonary artery catheters
        e.     Understands the sources of error and realises the limitations of measurements made
               and indices derived and responds appropriately
        f.     Understands the risk/benefit ratio
        g.     Knows the complications of pulmonary artery catheters and acts to prevent them
        h.     Differentiates real change from artefact
        i.     Responds appropriately

6.3.7   Intracranial pressure
                                                23




      General Instructional Objective

      Understands the principles of intracranial pressure measurement, its relationship to cerebral
      perfusion pressure and the relevance of these to clinical practice.

      Required Abilities and Qualities

      a.      Knows the systems available for intracranial pressure monitoring, the principles
              involved and the type and site of placement of the monitoring device
      b.      Understands the advantages and disadvantages of the different systems
      c.      Knows the indications for intracranial pressure measurement
      d.      Knows the limitations of intracranial pressure measurement
      e.      Understands factors and therapies which may influence intracranial and cerebral
              perfusion pressure
      f.      Recognises changes in intracranial and cerebral perfusion pressure which are life
              threatening
      g.      Understands the risk/benefit ratio of intracranial pressure measurement
      h.      Differentiates real change from artefact
      i.      Responds appropriately
      j.      Safely and efficiently manages or contributes to the insertion and maintenance of an
              intracranial pressure monitor

6.4   Laboratory Investigations Relevant to Intensive Care Practice

      General Instructional Objective

      Knows the range and reliability and understands the indications for use and interpretation of
      laboratory tests relevant to intensive care practice and orders them appropriately.

      Required Abilities and Qualities

      a.      Knows the indications for the investigation
      b.      Knows the causes of abnormality and sources of error
      c.      Understands the concepts of sensitivity and specificity of the investigation as related
              to a specific disease
      d.      Understands how rapidly some investigations (eg. biochemical and haematological)
              can change in a critically ill patient and that a single normal result is not as
              significant as identifying trends of change by repeated testing where indicated
      e.      Recognises changes which are significant
      f.      Recognises changes which are potentially life threatening
      g.      Responds appropriately
      h.      Uses results to assist in diagnosis and management
      g.             Extends the breadth and repeats investigations appropriately

6.5   Organ Imaging

      6.5.1   Plain x-rays (eg. chest x-ray (CXR))

      General Instructional Objective

      Uses the CXR effectively in the intensive care patient.

      Required Abilities and Qualities
                                                24




      a.      Knows the indications for CXR in ICU patients
      b.              Knows the limitations of CXR in ICU patients
      c.              Knows the range of normal features on the CXR
      d.      Understands and interprets the effect of projection, position, penetration and other
              factors on the image quality and radiological signs
      e.      Recognises abnormalities, especially those which may be life threatening, and
              responds appropriately
      f.      Proposes a differential diagnosis based on the abnormalities observed
      g.      Relates the abnormalities to the clinical situation
      h.      Undertakes further investigations when indicated

      6.5.2   CT scanning, MRI, ultrasound, angiography and radionucleotide studies

      General Instructional Objective

      Understands the principles of CT scanning, MRI, ultrasound, angiography and
      radionucleotide studies in the intensive care patient and uses these investigations
      appropriately.

      Required Abilities and Qualities

      a.      Knows the indications for the procedure in ICU patients
      b.      Knows the limitations of the procedure in ICU patients
      c.      Understands the risk/benefit ratio of the procedure (including transport)
      d.      Recognises common abnormalities in the ICU patient
      e.      Seeks specialist radiological help to define more complicated problems
      f.      Proposes a differential diagnosis based on the abnormalities observed
      g.      Relates the abnormality to the clinical situation
      h.      Undertakes further consultation/investigation when indicated

6.6   Diagnostic ECG

      General Instructional Objective

      Understands the principles of diagnostic electrocardiography and uses it effectively.

      Required Abilities and Qualities

      a.      Knows the indications for ECG
      b.      Knows the limitations of ECG
      c.      Understands the usefulness of special leads in resolving difficult diagnostic issues
              (V4R - right ventricular infarction, oesophageal lead - SVT vs VT)
      d.      Interprets abnormalities correctly
      e.      Recognises changes needing urgent intervention
      f.      Undertakes appropriate treatment

6.7   Respiratory Function Tests

      General Instructional Objective

      Understands the principles of respiratory function tests and uses them effectively.

      Required Abilities and Qualities
                                                 25




       a.     Knows the various types of respiratory function tests and their indications for use
       b.     Knows their limitations in general and specifically in intensive care patients
       c.     Interprets abnormalities correctly
       d.     Undertakes appropriate treatment
       e.     Undertakes further consultation/investigation where indicated

6.8    EEG and Evoked Potentials

       General Instructional Objective

       Understands the principles of EEG and evoked potentials.

       Required Abilities and Qualities

       a.     Knows the indications for EEG and evoked potentials
       b.     Knows the limitations of EEG and evoked potentials
       c.     Is guided by expert opinion in interpretation
       d.     Undertakes appropriate treatment

6.9    Selection of Apparatus

       General Instructional Objective

       Selects apparatus based upon clinical need whilst ensuring its accuracy, reliability, safety
       and, where possible, its user friendliness.

       Required Abilities and Qualities

       a.     Demonstrates a need for the apparatus
       b.     Obtains estimate of initial cost, availability of servicing and ongoing costs
       c.     Verifies its accuracy against a known "gold standard" where appropriate
       d.     Seeks expert opinion where necessary to verify its safety, reliability and that it meets
              recognised standards
       e.     Demonstrates its ease of use and acceptance by staff
       f.     Understands its limitations
       g.     Assigns a priority to the need for the apparatus

6.10   Electrical Safety

       General Instructional Objective

       Understands and implements the principles of electrical safety as applied to intensive care.

       Required Abilities and Qualities

       a.     Understands the difference between macro-shock and micro-shock and the
              conditions which predispose to their occurrence
       b.     Knows the physical dangers of electrical currents
       c.     Knows the relevant standards document dealing with the safe use of electricity in
              patient care
       d.     Understands the basic methods by which electrical hazards are reduced
                                                26



       e.     Seeks expert help in ensuring that the Intensive Care Unit and all electrical
              equipment used in patient care conforms with and is maintained to the relevant
              safety standard

6.11   Ionising Radiation

       General Instructional Objective

       Understands and implements the principles of ionising radiation as applied to intensive care.

       Required Abilities and Qualities

       a.     Knows the hazards associated with ionising radiation
       b.     Seeks expert opinion in limiting these hazards

6.12   Computer Applications

       General Instructional Objective

       Understands the principles of computer applications in intensive care.

       Required Abilities and Qualities

       a.     Defines areas where computer applications might be helpful
       b.     Seeks expert opinion on establishing computer services
                                                 27




SEVEN        CARDIOPULMONARY RESUSCITATION
7.1   Introduction

      Cardiopulmonary resuscitation of a critically ill or injured patient may be required within
      the hospital in the Intensive Care Unit, emergency department or in a hospital ward or
      department or outside the hospital whilst on a patient retrieval or attendance at a disaster
      scene.

7.2   Cardiopulmonary Resuscitation

      General Instructional Objective

      Understands and applies the principles of resuscitation from respiratory or cardiorespiratory
      arrest in patients of all ages. Appreciates that the time to basic life support and defibrillation
      are the critical variables in the probability of survival from cardiac arrest.

      Required abilities and Qualities

      a.     Recognises symptoms and signs of impending cardiac arrest
      b.     Knows the causes of cardiorespiratory arrest and seeks to identify the cause in
             individual cases (especially the rapidly reversible causes)
      c.     Knows the effects of cardiorespiratory arrest on body systems
      d.     Knows and applies corrective treatment
      e.     Constructs a plan of management for either ventricular fibrillation or
             asystole/pulseless electrical activity
      f.     Demonstrates techniques to clear and maintain the airway and use of mouth-to-mask
             ventilation and the use of self-inflating hand held resuscitators on patients and
             models
      g.     Understands the principles and demonstrates techniques of external cardiac
             compression
      h.             Demonstrates combined mechanical ventilation and external cardiac
             compression in one person and two person rescue
      i.             Knows the indications and demonstrates the operation of external
             defibrillators (manual and shock advisory)
      j.     Performs endotracheal intubation in emergency circumstances
      k.     Understands the principles of operation and demonstrates the use of devices used in
             cardiopulmonary resuscitation
      l.     Knows techniques of access to the circulation
      m.     Diagnoses cardiac dysrhythmias
      n.     Prescribes correct anti-dysrhythmic therapy
      o.     Knows the protocols of the Australian Resuscitation Council for management of
             cardiorespiratory arrest and demonstrates familiarity with other international
             protocols
      p.     Recognises complications and sequelae of cardiopulmonary resuscitation and knows
             management
      q.     Counsels relatives or guardians of patients during and after cardiac arrest
      r.     Responds to an emergency in a positive, organised and effective manner, and can
             direct the resuscitation team
      s.     Knows the indications to start and stop cardiopulmonary resuscitation

7.3   Administration
                                               28



      Organisation of Response to Cardiorespiratory Emergency

      General Instructional Objective

      Understands the organisation required for an effective cardiopulmonary resuscitation
      service within a hospital and participates in a hospital response to internal and external
      disasters.

      Required Abilities and Qualities

      a.     Recognises the requirements for all areas within a hospital
      b.     Organises provision of equipment for areas within a hospital
      c.     Organises attendance of appropriate personnel at site of cardiorespiratory arrest
      d.     Understands the design and equipment requirements for a resuscitation facility
      e.     Participates in organisation of personnel and equipment to respond to an internal or
             external disaster

7.4   Training of Medical and Other Staff

      General Instructional Objective

      Train and direct training of medical, nursing and paramedical personnel.

      Required Abilities and Qualities

      a.     Teaches techniques of cardiopulmonary resuscitation to different personnel
      b.     Understands the problems of resuscitation which confront non-medical personnel
                                                29




EIGHT                TRANSPORTATION OF
                     CRITICALLY ILL PATIENTS
8.1   Introduction

      Transportation of critically ill patients is required in a number of circumstances. It may be
      pre-hospital, intra-hospital for diagnostic and/or therapeutic interventions and interhospital
      for specialised diagnostic procedures and/or therapy that is only available in tertiary
      Intensive Care Units. Transport may be required on an emergency or semi-elective basis.
      The principle governing transport of critically ill patients is to maximise safety and at the
      same time to maintain or improve the patient’s clinical status during retrieval.

8.2   Organisation and Operation of Retrieval Services

      General Instructional Objectives

      Understands the principles, problems and risks, and applies this knowledge to ensure
      appropriate and safe transport of critically ill patients. Knows the Joint Faculty Document
      IC 10, Minimum Standards for Transport of the Critically Ill.

      Required Abilities and Qualities

      a.     Knows the principles underlying safe transport of critically ill patients of all ages
      b.     Understands the importance of prior planning and organisation of retrieval services
      c.     Understands the requirement for stabilization and support of the critically ill patient
             before transport is commenced
      d.     Understands the need for specially designed equipment, taking into consideration
             size, weight, battery life, durability and performance under conditions of transport
      e.     Appreciates the importance of communication between referring, transporting and
             receiving staff
      f.     Knows how to select and train appropriate staff based on patient need
      g.     Understands the advantages and disadvantages of road ambulance, fixed and rotary
             wing aircraft including the problems associated with altitude, noise, vibration,
             acceleration and deceleration
      h.     Knows how to select the mode of transport based on clinical requirements, distance,
             vehicle availability and environmental conditions
      i.     Appreciates the importance of pre-transport consultation and advice, especially
             when lengthy delays are anticipated
      j.     Understands the potential mental and physical trauma to the patient and the
             traumatic effects of family dislocation
      k.     Understands the operation of a locally available retrieval service
      l.     Understands the need for complete documentation of the patient’s clinical condition,
             before during and after transport, relevant medical conditions, therapy delivered,
             environmental factors and logistical difficulties encountered
      m.     Understands the need for regular audit of all aspects of retrieval and application of
             Quality Improvement principles
      n.     Understands the adaptation and application of general retrieval principles where
             appropriate to pre-, intra- and interhospital transport
                                                  30




NINE           TECHNICAL SKILLS
9.1     Introduction

        The trainee must become proficient in a wide range of technical skills necessary for
        therapeutic and monitoring purposes. The ability to perform procedures must be
        accompanied by a knowledge of indications, contraindications and complications. The
        latter includes not only physical hazards, but possible delays in instituting obviously needed
        therapy whilst procedures are undertaken and the possibility of obtaining and acting upon
        wrong information. A representative list of procedures is shown in Appendix 3.

9.2     General Instructional Objective

        Knows what preliminary measures must be undertaken, confirms that they have been done
        and then skilfully performs the procedure in a manner which minimises the risks of
        complications.

        Required Abilities and Qualities

        a.     Performs those procedures which are accepted in the hospital as within the
               competence of the Intensive Care Unit specialist and,
        b.     seeks consultation for the performance of those procedures which are not
        c.     Understands the importance of preliminary preparation before undertaking a
               procedure
        d.     Knows relevant anatomy and how physiological function may be altered during the
               procedure
        e.     Knows the complications, how to recognise them and institute appropriate
               management
        f.     Performs the procedure and carries out continuing management in a manner which
               minimises the risks of complications

9.3     Example

9.3.1   Insertion of a Pulmonary Artery Thermodilution Balloon Tipped Flotation Catheter

        General Instructional Objective

        Knows what preliminary measures must be undertaken, confirms that they have been done
        and then skilfully inserts the pulmonary artery catheter in a manner which minimises the
        risks of complications.

        Required Abilities and Qualities

        a.     Obtains informed consent from the patient or guardian where appropriate
        b.     Checks the ready availability of functional resuscitation equipment and ensures
               close observation, continuous ECG monitoring and pulse oximetry are being
               undertaken
        c.     Knows the complications of the technique, how to recognise them and initiate
               appropriate management
        d.     Ensures the correct setting up, zero and calibration of pressure monitoring
               equipment
        e.     Chooses an appropriate route of insertion and positions the patient correctly
                                       31



f.   Scrubs, gowns and gloves, prepares a sterile field and applies sterile drapes so that
     the procedure can be performed in an aseptic manner
g.   Checks that appropriate instruments and equipment are available and functional.
     Confirms balloon and thermodilution wire integrity and flushes pressure monitoring
     lumens with sterile saline without compromising the sterile field
h.   Infiltrates the skin and subcutaneous tissue with local anaesthetic where appropriate
i.   Uses knowledge of anatomy when cannulating the vein
j.   Inserts catheter using techniques to eliminate risk of air embolism
k.   Inflates the balloon and observes the pressure trace as the balloon catheter is
     advanced through the right heart and into the pulmonary artery to the wedged
     position
l.   Deflates the balloon confirming the underlying undamped pulmonary artery trace
     returns
m.   Adjusts catheter position if necessary such that 1-1.5cc of air introduced into the
     balloon port achieves a wedged trace
n.   Secures the catheter
o.   Applies a sterile dressing
p.   Obtains chest x-ray to confirm correct catheter position and excludes pneumothorax
                                                 32




TEN           PAEDIATRICS
10.1   Introduction

       The level of knowledge and skills to be acquired is that which is expected of an Intensivist
       working in a general Adult Intensive Care Unit into which a paediatric patient might be
       admitted for a limited period of time, and from which the patient might be transferred to a
       Paediatric or Neonatal Unit. In addition to specific paediatric problems, trainees should be
       familiar with the paediatric management of conditions common to both children and adults
       eg. acute severe asthma, renal failure, trauma etc. Trainees seeking endorsement in
       Paediatric Intensive Care will require a more detailed knowledge than is implied in this
       section of the document.

10.2   Care of the Critically Ill Child

       General Instructional Objective

       Is able to recognise and resuscitate paediatric patients with life-threatening conditions,
       institute appropriate intensive care management, and when required, prepare for transport to
       a Paediatric or Neonatal Intensive Care Unit.

       Required Abilities and Qualities

       1.     General knowledge

              a.      Demonstrates a knowledge of the anatomical, physiological,
                      pharmacological and psychological differences between neonates, infants,
                      small children and adults
              b.      Applies these differences in the resuscitation and management of critically ill
                      paediatric patients

       2.     Knowledge of specific disorders that may be life threatening to paediatric patients
              and that require intensive care management

              a.      Knows the pathophysiology and principles of management of disorders
                      which are life-threatening to paediatric patients

       Note: Basic knowledge of some major neonatal conditions is required in as much as they
             relate to neonatal physiology, therapeutic principles and childhood morbidity

              Important disorders specific to neonates include congenital heart disease, persistent
              pulmonary hypertension, acute neonatal lung diseases, bronchopulmonary dysplasia,
              tracheo-oesophageal fistula, diaphragmatic hernia, gastroschisis/exomphalos and
              necrotising enterocolitis

       3.     Techniques

              Knows and uses efficiently the intensive care techniques specifically used in the
              management of critically ill children

              Examples include acute resuscitation, monitoring, management of ventilation,
              circulatory support and care during transportation
                                                33




ELEVEN                       ETHICS
11.1   Introduction

       An understanding of the principles of Ethics is essential for development and maintenance
       of the highest standards of practice, teaching and research in Intensive Care.

11.2   Principles of Medical Ethics

       General Instructional Objective

       Understands the concepts of patient autonomy, beneficence, non-maleficence and justice (as
       it applies to fair distribution of resources).

       Required Abilities and Qualities

       a.     Understands that patients or their guardians have the right to accept or reject a
              treatment being offered (with due regard to the principles of truthful disclosure and
              informed consent)
       b.     Understands the issues and principles involved in withholding and withdrawing
              treatment, and the care of the dying patient
       c.     Understands that the decision to withhold or withdraw treatment does not imply the
              termination of care
       d.     Understands the ethics of resource allocation in the face of competing claims to care
       e.     Understands the issues and principles involved in the diagnosis of brain death and
              the process of organ donation and can demonstrate understanding using role play
       f.     Understands that when patients are involved in teaching, the principles of consent,
              privacy and non-maleficence must be maintained
       g.     Understands the ethical principles involved in conducting research and the need for
              Institutional Ethics Committee approval of the proposed research (see 13.4.3)
       h.     Knows that the well-being of the patient takes precedence over the interests of
              society or research
       i.     Behaves with integrity and honesty and accepts responsibility for his/her personal
              physical and mental health, especially where impairment of health affects patient
              care and professional conduct
       j.     Appreciates the potential role of the intensivist in improving the standard of health
              care in the community
                                                 34




TWELVE                       ADMINISTRATION AND
                             QUALITY ASSURANCE


12.1   Introduction

       In addition to acquisition of clinical skills (problem solving, procedural, treatment), the
       trainee should become familiar with the broader activities of an ICU. These concern the
       efficient running of a unit (administration, organisation, staffing, design and equipment),
       and the need for clinical audit and quality improvement programmes. Unit practice must be
       conducted according to ethical principles and fulfil medicolegal requirements. Participation
       in hospital committees, the organisation of scientific meetings, and the activities of
       professional organisations are desirable.


12.2   Administrative Responsibilities of an Intensive Care Specialist

       General Instructional Objective

       Understands the non-clinical roles of an Intensive Care Unit specialist and understands how
       such activities contribute to the efficiency of the Intensive Care Unit, the profile of
       intensive care within the hospital and hence, indirectly to the quality of patient
       management.

       Required Abilities and Qualities

       a.     Knows the duties of an Intensive Care Unit specialist and the Director of the
              department
       b.     Understands the principles of administration and management
       c.     Understands the principles of departmental budgeting, financial management and
              resource utilisation
       d.     Refers to the appropriate standards and knows the physical requirements of
              Intensive Care Unit design
       e.     Understands the factors that determine the optimum staff establishment for specialist
              and junior medical staff, nurses, paramedical and secretarial staff
       f.     Understands the process for selecting, ordering and maintaining equipment
       g.     Contributes to Unit activities and encourages others to do so
       h.     Recognises impaired performance in self and in professional colleagues
       i.     Contributes to professional meetings and understands their rules, structure and
              etiquette
       j.     Understands the issues involved in organising a scientific meeting
       k.     Understands the ethical and legal implications of intensive care practice (see also
              Chapter 11)


12.3   Clinical Audit and Quality Improvement

       General Instructional Objective

       Is able to undertake clinical audit and performs effective quality improvement activities.
                                         35



Required Abilities and Qualities

a.     Understands the need for and can undertake clinical audit (eg. mortality reviews,
       complications etc) and review other clinical indicators
b.     Understands the purpose and process of other quality improvement activities such as
       evidence based practice, best practice guidelines, bench marking and critical
       pathways
c.     Recognises the need for clinical audit and quality improvement activities not to be
       threatening or punitive to individuals
d.     Encourages others to participate in clinical audit and quality improvement activities
e.     Complies with Joint Faculty recommendations for quality improvement activities
       (Document IC-8 ‘Quality Assurance’)
                                                 36




THIRTEEN                     RESEARCH IN
                             INTENSIVE CARE
13.1   Introduction

       Intensive Care Unit specialists are required to evaluate the medical literature as a basis for
       continuing education, maintenance of professional standards and continuous quality
       improvement of patient care. It is also desirable that Intensive Care Unit specialists
       undertake and foster high quality clinical research. For this to be achieved, an extensive
       knowledge of scientific processes and ethics is required.

13.2   Teaching and Learning through Research

       General Instructional Objective

       Understands and uses the “scientific approach” in continuing education and educational
       activities.

       Required Abilities and Qualities

       a.     Values and uses a scientific approach to analyse and solve problems encountered
       b.     Describes the general and specific tests to solve a problem
       c.     Describes common statistical principles and tests and their usefulness
       d.     Describes the importance of good record keeping in research and keeps such records
       e.     Explains ethical considerations in research involving human or animal subjects
       f.     Is able to describe the steps, and prepare a protocol, involved in both hypothesis
              generated research (for example, evaluation of a therapeutic agent) and
              observational research

13.3   The Scientific Method

13.3.1 Identifying the need for investigation

       General Instructional Objective

       Perceives the difference between those patterns of practice, or approaches to patient
       problems, or problems themselves, which have a sound scientific basis and those that
       require further objective assessment.

       Required Ability and Quality

       Has the insight and knowledge to identify observations which are unusual or unexplained
       and worthy of investigation

13.3.2 Formulating the hypothesis

       General Instructional Objective

       Understands the process of advancing a theoretical explanation for an observation.

       Required Abilities and Qualities
                                                 37



       a.     Uses logical processes, based on acquired knowledge or experience to explain
              observations
       b.     Identifies underlying scientific principles which may govern the observed events

13.3.3 Library search and literature review

       General Instructional Objective

       Understands and uses library resources effectively, to evaluate and refine an hypothesis and
       to develop appropriate experimental methods.

       Required Ability and Quality

       Demonstrates ability to collate and critically appraise relevant material

13.3.4 Reliability of proposed method in investigation

       General Instructional Objective

       Understands the principles of experimental trial design and methods of measurement which
       are appropriate for the proposed investigation.

       Required Abilities and Qualities

       a.     Appreciates concepts of validity, reproducibility and accuracy in the application of
              measurement techniques
       b.     Seeks out resources and assistance available locally
       c.     Understands how to validate selected methods

13.4   Experimental Design

13.4.1 Writing a protocol and seeking advice

       General Instructional Objective

       Appreciates the process required to develop a research protocol.

       Required Abilities and Qualities

       a.     Demonstrates ability to organise, or assists in organising a written description of the
              proposed method of study
       b.     Seeks advice from others with interest or expertise in the field of study
       c.     Appreciates the need for effective communication with collaborators and other staff
              whose work may be affected by the proposed research

13.4.2 Statistical advice

       General Instructional Objective

       Understands the need to have sound statistical knowledge and/or advice before
       commencing data collection.

       Required Abilities and Qualities
                                                  38



       a.     Appreciates the importance of sample size to the statistical power of the
              investigation
       b.     Other abilities as outlined below in 13.5

13.4.3 Ethical considerations

       General Instructional Objective

       Understands both the ethical principles involved in conducting research and the need for the
       Institutional Ethics Committee’s approval of the proposed research.

       Required Abilities and Qualities

       a.     Learns and cares about such aspects as:
              - informed consent and protection of every subject’s rights and autonomy,
                 (including explanation of potential risks, discomforts, benefits to the subject from
                 participating in the study and the right to withdraw from the study without
                 compromising care)
              - protection of the subject’s confidentiality in research
              - medicolegal implications of the proposed research
       b.     Demonstrates the ability to organise, or assist in organising, a written application to
              the Institutional Ethics Committee for approval of the proposed investigation,
              method of study and research consent form
       c.     Understands that only ethical research is research of good quality

13.4.4 Obtaining and Using Resources

       General Instructional Objective

       Understands the process by which research funds are obtained and how to write a grant
       application.

       Required Abilities and Qualities

       a.     Prepares or assists in preparing a grant application
       b.     Appreciates the importance of interdisciplinary co-operation and sharing of scarce
              research resources, equipment and facilities

13.5   Statistical Analysis

13.5.1 Choosing and applying appropriate statistical tests

       General Instructional Objective

       Understands the principles of statistical inference.

       Required Abilities and Qualities

       a.     Understands the importance of statistical concepts eg. distribution of data,
              comparisons of distributions and their tests, probability, confidence intervals,
              permitted departures from distributional assumptions, parametric and non-
              parametric statistical tests
       b.     Understands potential errors in interpretation and application of statistics
                                                39



13.5.2 Interpretation of results

       General Instructional Objective

       Learns to draw relevant conclusions strictly based on significant data derived from the
       study.

       Required Abilities and Qualities

       a.     Appreciates the limitations of investigations
       b.     Learns what inference is reasonable from the results
       c.     Applies similar scrutiny to other published work

13.6   Data Presentation

       General Instructional Objective

       Understands principles and develops skill at communicating data by written word, verbally
       and using visual aids.

       Required Abilities and Qualities

       1. Preparation of a manuscript for submission to a journal

              a.      Follows Uniform Requirements for Manuscripts submitted to Biomedical
                      Journals (The New England Journal of Medicine 1991;324:424-8) and
                      specific Guidelines for Authors
              b.      Submits or contributes materially to at least one original paper, for
                      publication in an appropriate journal

       2.     Preparation of visual material

              a.   Understands principles and develops skill at communicating data and concepts
                   using visual aids, in the lecture hall or on a poster
              b.   Prepares slides and posters of an acceptable standard
              c.   Critically appraises visual aids prepared by others
              d.   Recognises the limitations of visual aids

       3.      Presenting papers and posters at meetings

              a.   Understands principles and develops skill at communicating data and concepts
                   in the lecture hall or on a poster
              b.   Presents at least one original paper at an appropriate scientific meeting
                                                 40




FOURTEEN                      EDUCATION
14.1   Introduction

       Learning all aspects of the practice of intensive care medicine is fundamental to becoming
       a competent specialist. An understanding of educational principles will support the process
       of continuing education throughout professional life. Teaching of medical colleagues and
       other health professionals is both a responsibility and a continuing learning experience for
       the teacher.

14.2   Principles of Adult Learning

       General Instructional Objective

       Understands the factors that promote adult learning.

       Required Abilities and Qualities

       a.             Knows that learning is most effective when derived from past/present
              experience of the learner and from active participation in the learning process
       b.             Understands that a problem-solving mode, rather than a solution giving one,
              is required
       c.             Appreciates that the learning environment is best when characterised by
              freedoms and choices
       d.             Understands the requirement for self-dependence rather than dependency on
              any expert
       e.             Knows that objectives are best when they arise out of the interests and needs
              of the learner
       f.             Appreciates that the relationship between learner and teacher should be
              characterised by mutual trust, acceptance and respect
       g.             Knows that feedback from teacher and peers provides benefit and support
       h.             Understands that the environment for learning needs to be physically
              comfortable
       i.             Knows that humour and laughter improve the learning climate

14.3   Learning and Teaching

       General Instructional Objective

       Understands that learning and teaching are both ongoing rights and responsibilities of
       Intensive Care Unit specialists and can use the principles of adult learning to be an efficient
       student and teacher.

       Required Abilities and Qualities

       a.     Can use the principles of adult education to promote individual learning, teaching
              of others and continuing personal education
       b.     Understands the value of educational objectives and can write objectives for
              personal needs and for an education programme
       c.     Recognises and uses the teaching and learning opportunities arising from clinical
              experience
       d.     Understands and uses the opportunities for learning that arise from personal
              communication
                                      41



e.   Appreciates the range and qualities of written and audio-visual material and
     interactive computer programmes and other software in order to make best use of
     their potential for learning
f.   Recognises that properly conducted research (see Chapter 13) and a ‘scientific
     attitude’ are major contributors to teaching and learning
g.   Understands how evaluation can improve learning and teaching
h.   Understands the importance of certification examinations and defines their validity
     and reliability
                                                 42




FIFTEEN                       COMMUNICATION


15.1   Introduction

       The ability to communicate effectively is an essential attribute of the competent Intensive
       Care Unit specialist. Such communication is particularly important when it involves other
       ICU staff (other specialists, junior medical staff, nurses and paramedical staff), referring or
       consulting medical staff from outside the ICU, and patients and their families.


15.2   Effective Communication

       General Instructional Objective

       Understands the role of communication skills in the effective functioning of an Intensive
       Care Unit specialist and can access relevant resources to develop his or her own
       communication skills to an appropriate level.

       Required Abilities and Qualities

       a.     Recognises the need for effective communication with patients and/or their families,
              and medical and non-medical colleagues
       b.     Understands the principles of conflict resolution and negotiation
       c.     Appreciates the problems associated with difficult or stressful conditions eg. death
              (including brain death), withdrawal of therapy, organ donation
       d.     Understands the principles of crisis management and debriefing
       e.     Can access appropriate books, videos, courses etc to assist in development of
              personal communication skills
                                                  43



APPENDIX 1 - REPRESENTATIVE LIST OF MEDICAL, SURGICAL AND
             OBSTETRIC CONDITIONS

Cardiovascular Disorders
Shock
Cardiac dysrrhythmias and conduction disturbances
Congestive cardiac failure
Ischaemic heart disease and complications
Cardiopulmonary arrest
Cardiomyopathy
Endocarditis
Valvular heart disease
Aortic aneurysm
Pericardial disease
Systemic and pulmonary hypertension
Arterio-venous fistula
Arterial embolus or thrombosis
Peripheral arterial disease and other chronic arterial diseases
Deep vein thrombosis
Pulmonary embolism
Superior and inferior vena cava obstruction syndromes

Respiratory Disorders
Respiratory failure
Cardiogenic and non-cardiogenic pulmonary oedema and ARDS
Airway obstruction
Pneumothorax
Aspiration syndromes
Fat embolism
Pneumonia (community and nosocomial)
Collapsed lung or lobe
Chronic airway limitation
Asthma
Pulmonary abscess
Carcinoma of lung
Pleural disease
Airway stenosis and tracheomalacia
Diseases of the diaphragm
Bronchopleural fistula

Renal Disorders
Acute renal failure
Urinary tract infection
Pyelonephritis
Glomerulonephritis
Rhabdomyolysis
Carcinoma of bladder and kidney
Nephrotic syndrome
Renal tubular acidosis
Nephrolithiasis
Interstitial nephritis
Central Nervous and Neuromuscular Disorders
                                                 44



Acute vascular disorders of the central nervous system
Intracranial haematomas
Acute infective disorders of the central nervous system
Cerebral oedema
Global ischaemia
Brain death
Cerebral neoplasm, primary or secondary
Seizures
Hemiplegia, paraplegia, quadriplegia
Guillain Barre syndrome and other forms of acute polyneuritis
Peripheral nerve and or muscle dysfunction associated with critical illness
Myasthenia gravis
Toxic encephalopathy (acute brain syndrome)
Chronic cerebrovascular insufficiency
Bulbar palsy
Hyperthermia, hypothermia
Tetanus
Botulism
Delirium
Catatonia
Psychiatric aspects of attempted suicide

Endocrine Disorders

Diabetes mellitus
Pituitary and hypothalamic disorders
Addison's disease
Cushing's syndrome, complications of steroid therapy
Conn's syndrome
Thyroid disorders
Hormonal responses to critical illness
Phaeochromocytoma
Obesity

Metabolic Disorders

Metabolic response to stress, sepsis, starvation, surgery and trauma
Electrolyte and acid-base disorders
Nutrition and malnutrition

Haematology, Oncology, Immunology, Rheumatology

Defects in haemostasis (eg. disseminated intravascular coagulation, thrombocytopaenia,
fibrinolysis, hypercoagulable syndromes)
Anaemia
Acute haemolytic disorders
Transfusion reactions
Common drug reactions
Anaphylaxis
Immunosuppression
Complications of transplantation eg. organ rejection
Febrile neutropaenia
Rheumatoid arthritis and related disorders
Auto-immune disease (systemic lupus erythematosis, polyarteritis nodosa)
                                               45



Human immunodeficiency virus (HIV) infection and its complications

Gastrointestinal Disorders

Gastrointestinal bleeding
-       Acute gastric erosions
-       Peptic ulceration
-       Bleeding oesophageal varices
Paralytic ileus, gastric dilatation
Ischaemia or infarction of gut
Bowel obstruction
Inflammatory bowel disease
Pseudo-membranous colitis
Peritonitis and intrabdominal sepsis
Post-operative GIT problems eg. leaking anastomosis, fistula, blind loop syndrome, malabsorption
Pancreatitis
Hepatic and biliary disease
-       Fulminant hepatic failure
-       Chronic liver disease
-       Ascites
-       Obstructive jaundice
-       Hepatic dysfunction associated with critical illness
-       Chronic alcoholism

Infectious Disorders
Infections - bacterial, viral, fungal, rickettsial and protozoal
Serious community acquired infections eg. meningococcal disease
Nosocomial infections, particularly with multiply resistant micro-organisms eg. MRSA
Sepsis, severe sepsis, septic shock and septicaemia
Toxic shock syndrome
Symbiotic gangrene (necrotising fasciitis)
Gas gangrene

Complications of Pregnancy and Gynaecological Disorders

Septic abortion
Pelvic inflammatory disease
Ectopic pregnancy
Eclampsia, pre-eclampsia
Amniotic fluid embolism
Obstetric haemorrhage

Dermatological Disorders

Erythema multiformae
Toxic epidermal necrolysis
                                                 46



Multisystem Disorders

Systemic inflammatory response syndrome (SIRS)
Multiple organ failure or multiple organ dysfunction syndrome (MODS)

Trauma

Maxillofacial and airway injuries
Chest injuries
Aortic injuries
Abdominal trauma
Neurotrauma including acute spinal cord injury
Pelvic injuries
Long bone trauma

Toxic, Chemical, Physical Agents

Drug overdose and poisoning
Ingestion or inhalation of corrosive or toxic substances including plants
Burns
Envenomation
Electrocution
Decompression syndromes
Altitude sickness
Hyperthermia
Hypothermia
Near drowning

Postoperative Care

Neurosurgical
Cardiothoracic
General

Organ Donation/Transplantation

Care of the organ donor
Complications of Transplantation
                                                 47



APPENDIX 2 -         REPRESENTATIVE LIST OF TREATMENTS
                     UNDERTAKEN IN THE INTENSIVE CARE UNIT


Fluid Therapy

                 •   crystalloid
                 •   colloid
                 •   blood
                 •   blood component

  Drug Therapy

                 •   inotropes
                 •   vasodilators
                 •   vasoconstrictors
                 •   antidysrrhythmics
                 •   analgesics
                 •   sedatives
                 •   antimicrobial agents
                 •   corticosteroids
                 •   anticoagulants, thrombolytics, fibrinolytics


  Respiratory Therapy

                 •   oxygen therapy
                 •   CPAP
                 •   mechanical ventilation, including modes of ventilation
                 •   weaning
                 •   nitric oxide administration
                 •   ECMO
                 •   partial liquid ventilation


  Cardiac Support

                 •   use of inotropes, constrictors, dilators
                 •   pacemaker insertion
                 •   intra-aortic balloon pumping
                 •   cardioversion

  Renal Replacement Therapy

                 •   haemo(dia) filtration techniques
                 •   haemodialysis
                 •   peritoneal dialysis
                 •   haemoperfusion
                 •   plasmapheresis
                                                 48
APPENDIX 3 -             REPRESENTATIVE LIST OF PROCEDURES RELEVANT
                         TO THE INTENSIVE CARE SPECIALIST

Expired air resuscitation

Bag-and-mask ventilation

Endotracheal intubation

Closed chest compression

Defribillation

Vascular access
                     •   peripheral venous
                     •   central venous (various sites)
                     •   arterial
                     •   cut down
                     •   intraosseous

Pericardiocentesis

Pleural drainage
                     •   needle
                     •   tube

Cricothyroidotomy

Tracheostomy (Percutaneous)

Setting appropriate parameters on mechanical ventilation

Right heart catheterisation

                     •   assessment of CVP, PAWP, cardiac output

Insertion of temporary pacing wire

Peritoneal lavage

Insertion of epidural catheter

Insertion of nasogastric and nasojejunal tube

Insertion of Sengstaken-Blakemore or other balloon tamponade tube

Fibreoptic bronchoscopy

Transthoracic or transoesophageal echocardiography

				
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