Pulmonary, Critical Care Medicine Rotations
The knowledge base, procedural skill level, and personal qualities required of a well-trained critical care and pulmonary practitioner are extremely broad. In addition, developing self-directed learning skills is an essential part of any program of adult education.
A variety of rotations, both required and elective, are available for each trainee's education. Electives may be selected at any time, according to each fellow's plans, in consideration with other scheduling requirements. Some electives are required for successful program completion.
Primary Required Rotations:
1. Pulmonary and Critical Care Medicine Consults
The purpose of this rotation is to provide a formal instruction and opportunities to acquire expertise in the prevention, evaluation, and management of patients with (but not limited to) obstructive lung disease, pulmonary malignancy, pulmonary infections, diffuse interstitial lung disease, occupational and environmental lung diseases, iatrogenic respiratory diseases, acute lung injury, pulmonary manifestations of systemic diseases, respiratory failure, disorders of the pleura & mediastinum, and genetic & developmental disorders of the respiratory system, Peri-operative evaluations and consults for patients in other ICU’s. Fellows have opportunities to perform bronchoscopy, including endobronchial ultrasound, thoracentesis, and chest tube placement. Fellows also become skilled at interpreting PFTs, cardiopulmonary exercise tests and sleep studies.
2. University Hospital Medical-Neurosurgical Intensive Care Unit
The purpose of this rotation is to provide formal instruction and opportunities to acquire expertise in the prevention, evaluation, and management of patients with (but not limited to) acute respiratory failure, acute renal failure, hemodynamic instability, overdoses and poisonings, sepsis, acute neurologic insults, acute electrolyte and endocrine emergencies and coagulation disorders. In addition, exposure to acute phases and disease processes experienced during consult rotations is provided. Fellows have the opportunity to perform bedside ultrasonography and percutaneous tracheostomy.
3. Harry S. Truman Memorial Veterans Hospital Medical Intensive Care Unit
This rotation generally follows the same purpose, instruction, and exposure as the University Hospital Medical-Neurosurgical Intensive Care Unit and the Pulmonary Consult service at University Hospital. The patient’s in the VA-ICU are predominantly males, over 40 years of age, and they have a variety of complex medical problems.
4. Ambulatory Service
Fellows are assigned to the Ambulatory Service Rotation for 8-12 weeks each year. This rotation is aimed at enhancing fellows’ ambulatory experience by caring for walk-ins and semi-urgent out-patient consults. During this rotation, fellows will also have the opportunity to supervise and interpret cardiopulmonary exercise tests, interpret pulmonary function tests and sleep studies.
The purpose of this rotation is to provide the fellow with formal instruction and opportunities to acquire expertise in the prevention, evaluation and management of patients with (but not limited to) obstructive lung disease, pulmonary malignancy, pulmonary infections, diffuse interstitial lung disease, occupational and environmental lung diseases, iatrogenic respiratory diseases, pulmonary manifestations of systemic diseases, respiratory failure, disorders of the pleura and mediastinum, genetic and developmental disorders of the respiratory system, and peri-operative evaluations.
As part of their ambulatory experience, fellows also care for lung cancer patients during their rotation in the multi-disciplinary lung cancer clinic at Ellis Fischel Cancer Center.
5. Research
The goal of the research component of the fellowship is to train physicians and basic scientists who want to pursue a career in academic medicine. Each fellow is expected to complete a research project of clinical or basic science interest. The duration of this training experience over a three year period depends on the needs of the individual fellow. The program develops independence under the direction of a mentor. A major emphasis of the experience is teaching the skills necessary to perform research and win peer-reviewed funding in our current competitive climate. The research process includes experience in literature review, study design, budgeting, peer review, IRB approval, data collection, statistical analysis, and submission of an abstract for society presentation and publication in a peer-reviewed journal. In addition to the support of the teaching faculty, the fellowship program provides research support consisting of clinical research assistants, computer programming for data analysis, and graphics and audio/visual support for presentations.
Elective Rotations
Elective rotations have been arranged in various areas to expose the fellow to multidisciplinary aspects of pulmonary and critical care medicine. The rotations are mostly of one month duration.
1. Cardiac Intensive Care Unit (CICU)
This required elective rotation provides clinical experience in the specific are of cardiovascular disorders. The fellow joins the cardiac intensive care unit team in taking direct patient care responsibility of admissions to the CICU and their subsequent hospital course until discharge. Fellows learn the indications, contraindications, limitations and complications of pericardiocentesis, transvenous pacemaker insertion and thrombolytic therapy for acute myocardial infarction. Emphasis will be placed on the hemodynamics of congestive heart failure, acute myocardial infarction and valvular heart disease.
2. Respiratory Therapy
This required elective rotation enables fellows to learn the role of the respiratory therapist in the practice of pulmonary and critical care medicine and gain experience in issues of medical management of respiratory therapy. Fellows assist the respiratory therapist in bronchodilator administration, mechanical ventilator management and arterial blood gas analysis. During this rotation, fellows also gain experience in setting up, assisting in, and routine maintenance required for fiberoptic bronchoscopy.
3. Pulmonary Function Laboratory
This rotation is designed for the fellow to learn the physiologic basis for pulmonary function/exercise testing and to develop a technical proficiency in conducting these studies. Fellows will be provided the opportunity to develop expertise in the management of a pulmonary function laboratory and gain practical exposure in monitoring and assisting in the performance of bronchial provocation tests, as well as cardiopulmonary exercise tests.
4. Anesthesiology
This required elective rotation will focus on the management and control of the airway. The fellow will learn airway maintenance both with and without adjuncts. Ample opportunity is provided for practical experience with endotracheal intubation. Fellows are exposed to issues of patient management in the perioperative period which are unique to this environment.
5. Cardiothoracic Surgery
This required elective rotation provides clinical experience in the specific area of surgical cardiothoracic disorders. The rotation is focused on surgical pulmonary disorders, but there is also exposure to cardiac disorders including pre- and post-operative management of patients. Active participation in some procedures including, but are not limited to: chest tube thoracostomy, flexible bronchoscopy, rigid bronchoscopy, endobronchial stent placement, thoracentesis, placement of venous and arterial devices, management of chest tubes including the appropriate use of thrombolytics and pleurodesis, thoracoscopy, ECMO, and pericardiocentesis. In addition, fellows directly observe cardiothoracic surgery cases in the operating room.
6. Sleep Disorders
This required elective rotation offers experience in the diagnosis and treatment of sleep disorders. Fellows perform consultations on patients with sleep disorders, gain technical experience in performing polysomnography, learn how to interpret studies, and participate in the longitudinal management of patients with sleep disorders under the supervision of highly experienced, sleep-trained physicians.
7. Burn ICU
This elective rotation enables participation in the care of burn patients. Management of the burn patient will address the following: evaluation and control of the airway, fluid resuscitation, hemodynamic changes, ventilator management including the use of the Volumetric Diffusive Respirator (high frequency percussive ventilator), and the treatment of infections.
8. Pediatric Critical Care
This elective rotation enables fellows to participate in the care of critically ill pediatric patients. The assigned fellow rotates through the pediatric intensive care unit and the neonatal intensive care unit. In each unit, fellows actively participate in patient management under the direction of the unit attending. It is expected that fellows will instruct the pediatric residents in the areas of pulmonary and critical care medicine. Hemodynamics, ventilator management and the unique differences in treating pediatric as compared to adult patients are just some of the areas which will be addressed by this rotation.
9. Nephrology
This elective rotation enables fellows to learn the role of dialysis in the care of the critically ill patient. The fellow will join the nephrology consult team in assessing patients in all critical care units. The opportunity will be provided to learn the indications, contraindications, limitations and complications of peritoneal dialysis, hemodialysis, ultrafiltration, continuous arteriovenous hemofiltration and continuous venous - venous hemofiltration. Arrangements can also be made for the fellow to rotate in the hemodialysis and peritoneal dialysis units.
10. Neurosurgical ICU
This elective rotation enables fellows to participate in the care of neurosurgical patients. This rotation provides an opportunity to learn the indications, contraindications, limitations and complications of intracranial pressure monitoring. Fellows are expected to take an active role in therapeutic decisions including providing input in mechanical ventilator management and other issues relating to pulmonary disease and critical care medicine. Management of intracranial hypertension, the acute CNS trauma patient, closed head injury, the postoperative craniotomy patient, and the diagnosis of brain death are just some of the areas that are covered during this rotation.
11. Pediatric Pulmonology
This elective rotation enables fellows to participate in the care of pediatric pulmonary patients. Fellows also participate in the Cystic Fibrosis clinic. Management of pediatric asthma patients, congenital pulmonary defects and cystic fibrosis are just some of the areas that are specifically covered during this rotation.
12. Surgical ICU/ Trauma
A thorough knowledge of surgical critical care is an asset for trainees in critical care medicine, therefore, we strongly encourage a rotation in surgical critical care and trauma. This elective rotation enables fellows to participate in the care of postoperative and trauma patients. Fellows join the surgical intensive care unit team and are expected to actively participate in the management of these patients. Management issues specific to the perioperative and acute trauma patient are addressed.
13. Pulmonary Rehabilitation
This nationally-accredited pulmonary rehabilitation service works in close collaboration with the Pulmonary Division. Highly trained staff provides services, prescribed by a physician, to assess, evaluate, monitor, and educate patients with abnormalities of pulmonary function. Such patients undergo exercise sessions under close supervision. Fellows have the opportunity to observe and interact with patients, and they are able to observe and evaluate the patients during their rehabilitation.
