Mayne Academy of Critical Care

To ensure medical students graduate as competent junior doctors, it is important they develop the ability to recognise critical illness, direct perioperative management, and understand the fundamental aspects of unscheduled emergency care, including lifesaving treatment. To achieve this, the Mayne Academy delivers its Critical Care Course through student rotations in the UQ Medical School's clinical schools in the final year of the medical program. The Critical Care Course covers the specialties of Emergency Medicine, Anaesthesia and Intensive Care Medicine.

The course is delivered using a range of mechanisms including:

• e-learning
• practical bedside learning in hospitals
• simulation learning

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Goals of UQ learning in Critical Care

By the end of the UQ MD Program, graduates will:

• be prepared for their mandatory rotation to an Adult Emergency Department as an intern;
• be prepared to provide pre- and post- operative medical care to surgical patients;
• be able to recognise critically ill and deteriorating patients in the ward and emergency department, to commence appropriate immediate management, and to communicate the most relevant information when seeking assistance from senior colleagues;
• be able to provide immediate support of airway, breathing and circulation in a life-threatening emergency, including as a team leader during a cardiac arrest by applying Basic and Advanced Life Support protocols;
• regardless of their future specialty, be able to manage the critical care aspects of treatment relevant to other medical specialties including primary care; and
• have sufficient knowledge of anaesthetics, intensive care and emergency medicine to inform future career choices.

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Our specialties

Anaesthetics

Anaesthesia is the largest single hospital specialty. Modern anaesthesia is highly interdisciplinary spanning the perioperative medical needs of patients, from preoperative medical assessment and optimisation for surgery, intraoperative management maintaining physiology, analgesia and rendering patients unconscious, to postoperative medical and pain management. If considered a single disease, perioperative morbidity would be the 3rd largest cause of death worldwide. An epidemic of perioperative morbidity is occurring as demographics shift to older, frailer and multi-comorbid patients. Anaesthetics is at the forefront of the perioperative optimisation of this demographic.

At least some knowledge of the practice of intraoperative anaesthesia is relevant to virtually every doctor at some stage of their career, but particularly to interns who will be primarily responsible for preparing patients for surgery and for their routine postoperative ward care. As knowledge of preoperative optimisation increases, the role of primary care and medical specialty treatment in the months prior to surgery has also been appreciated, as has the role of general practitioners in managing the long-term medical complications of surgery (such as postoperative cognitive impairment) in an increasingly frail surgical population.

Notwithstanding the above, the value of experience in the intraoperative setting should not be dismissed, even for students who will never work in this environment after medical school. In no other context will the student routinely observe such dramatic changes in patient physiology or response to pharmacological treatment. Similarly, in no other location will there be the opportunity to perform life-saving invasive procedures such as bag-valve-mask ventilation and endotracheal intubation in a manner that is closely supervised and safe for patients.

Anaesthetists are not solely concerned with intraoperative surgical management. Anaesthesia led the development of multidisciplinary chronic pain clinics, and continue to lead acute pain services in most hospitals. Anaesthetists commonly supervise hospital preoperative clinics run by surgical junior doctors. Anaesthetists manage patients in labour wards, emergency departments, medical imaging departments, and cardiac and vascular laboratories.

Anaesthesia is unique amongst the medical specialties in routinely offering prolonged 1:1 student access to senior doctors during their clinical rotation. Students frequently reflect that this learning opportunity allows them to consolidate points of uncertainty that have been covered in other parts of the Critical Care attachment.

Emergency Medicine

Emergency Medicine is a particularly important learning opportunity for medical students. It is a general speciality that not only exposes the student to many core skills required of interns, but that are also relevant to any later career choice. At any one time there is a wealth of clinical opportunity with tens (if not greater than hundreds) of patients in different zones of an Emergency Department.

As a general speciality the argument can be made that emergency medicine competencies can be learned elsewhere and when setting a curriculum, learning outcomes may fall in other disciplines. However, patients present to the ED often in an undifferentiated manner and different clinical environments have different operational agendas for a patient condition or diagnosis. The emergency department, along with general practice, is the only opportunity medical students have during their course to encounter patients before any other healthcare professional has made a presumptive diagnosis.

The more unique areas of emergency medicine tend to be:

• Triage
• Systems & design
• Patient flow
• Trauma (major and minor)
• Toxicology

The learning environment of the ED has many strengths, but the weaknesses can sometimes be the chaos and the busyness of clinical teachers. UQ has developed a range of teaching options that can counter these weaknesses, such as Protected Opportunistic Emergency Medicine Student Teaching (POEMS), Virtual Emergency Experience Teaching (VEET), End of the Multiple Bed-o-gram Teaching in ED (EMBED), and the Prepare to Think Emergency Medicine Course (PTTEM).

Most students at UQ comment that they have learned more in an ED block than others of similar duration.

Intensive Care Medicine

Intensive Care Units admit the most unwell patients of every specialty. Just under half the patients in most Australian ICUs undergo mechanical ventilation at some point, just under half are surgical patients and one-third are admitted from emergency departments. Approximately 10% die.

In their ICU rotation, students have their best opportunity:

• to observe disease processes at their most advanced stages (e.g. severe respiratory and cardiac failure, delirium, sepsis)
• to understand the technical methods that can be employed to treat these conditions (e.g. advanced modes of mechanical ventilation used for prolonged weaning, continuous renal replacement therapy, inotropic therapy guided by invasive pressure and cardiac output monitoring).
• to acquire skills in the recognition and treatment of acute deterioration in ward patients, including when and how to summon senior assistance.

Even if they never ultimately work in an intensive care unit, understanding the burdens of these treatments for patients, the debilitated state that such prolonged intensive care produces, and the consequent considerations applied by intensivists when deciding who to admit to the ICU is important for all hospital doctors including interns.

Furthermore, it is vital that junior hospital doctors recognise incipient critical illness in their patients and can respond appropriately. There is considerable overlap in these skills with those required in Emergency Medicine. The allocation of responsibility for learning skills related to recognition and immediate response to critical illness to Emergency Medicine in the tables below does not imply that Intensive Care Medicine has little to offer in this area; rather that typically students will spend longer in their Emergency Medicine attachment than in the ICU, and that there are aspects to the subsequent management of these patients that can only be observed after ICU admission. Accompanying Medical Emergency Teams to attend to deteriorating ward patients during the ICU attachment will remain an important learning experience.

Students who will progress to careers in primary care will be responsible for the long-term care of survivors of critical illness, usually without access to specific specialist support.

Many of the problems managed by intensivists are not technical in nature. While many medical specialties grapple with these issues, often they are only crystallised to the point of requiring decisive action in the ICU. Understanding such issues is a valuable learning opportunity for all doctors. Examples include:

• The importance of appropriate Advance Care Planning for End-of-Life decisions
• Organ Donation
• Withdrawal of life-sustaining treatment and palliative care
• Reconciling the demands on the healthcare system with the resources available, including in allocating life-prolonging treatments
• Risk management
• Investigation of critical incidents, root cause analysis, patient safety, clinician welfare
• Consolidating the competing demands of advice from various specialties into a prioritised coherent plan