Educational Purpose

The educational purpose of this rotation is to have the fellows gain experience with the diagnosis and management of patients who are critically ill, to gain experience with monitoring and supervision of such a unit, and to gain experience interaction with other physicians, the health care team, and patients and their extended families. The fellows gain experience with the diagnosis and management of surgical patients who are critically ill.

Teaching Methods

Attending Rounds consists of conference room and bedside teaching with discussion of mechanical ventilation and weaning, theoretical and practical experience with hemodynamic monitoring, review portable chest radiographs, computed axial tomograms, radionuclide scans, electrocardiograms, pulmonary angiograms, and other topics and procedures. The goal is to develop a meaningful, practical, and cost-effective approach to diagnosis and treatment of critically ill patients. Interaction and communication with the primary care providers, patients and families are stressed. Special emphasis is placed on cultural, socioeconomic, ethical, occupational, environmental, and behavioral issues.

Attending rounds also integrate the PharmD attending, residents, and students who contribute to the teaching especially in regards to pharmacokinetics, drug interactions, paralytic agents and parenteral nutrition.

Interaction with anesthesiologists and surgeons foster learning about use of anesthetic agents, difficult intubations, and other clinical problems that are primarily in the realm of anesthesiology and surgery.

Procedures: Performed under the supervision of the attending physician whose role gradually evolves to that of a critical observer as the fellow gains experience with establishment of and maintenance of open airway, intubation, invasive and non-invasive mechanical ventilation, liberating the patient from mechanical ventilation, insertion of central venous, arterial and pulmonary artery flotation catheters, calibration and operation of hemodynamic recording systems, use of paralytic and other agents required by critically ill patients, transcutaneous tracheostomy, basic and advanced cardiopulmonary resuscitation and parenteral nutrition.

Pathology: The fellows are expected to review the results of diagnostic studies that include bronchoalveolar, pleural fluid and tissue, and lung tissue specimens, with their attending physician and the pathology attending. Fellows are expected to review all deaths in detail. This includes obtaining and participating in the autopsy and questioning all aspects of the management of the case.

Case Conference: Diagnostic and therapeutic approach to pulmonary and critical care patients are discussed in detail along with the relevant literature on a weekly basis.

Disease Oriented Clinical Conference: Pulmonary, Critical Care, and Sleep Medicine diseases are covered in this weekly conference.

Principles of Practical Pulmonary Conference: Topics not identifiable as belonging a disease are covered in these weekly sessions. Subject matter includes physiology, procedures, and interpretations of tests.

Mix of Diseases, Patient Characteristics, and Clinical Procedures and Services

The patient population encountered at this tertiary hospital unit is very heterogeneous and includes all patients required by the curriculum including the direct care of surgery patients. There are two services each with an 8 intensive care bed. Patients with cardiovascular, respiratory, renal, gastrointestinal, genitourinary, neurologic, hematologic, musculoskeletal, immune and infectious diseases, hematologic and coagulation disorders, critical obstetric and gynecological disorders, immunosuppressed patients and patients with anaphylaxis and acute allergic reactions are encountered. The fellows see transplant patients with the different conditions which they have. The role of the fellow is that of a junior attending physician. The surgical patients have a broad variety of surgical related disease that includes cancers, sepsis, abdominal, urological, otolaryngologic disease and many others.

Fellow Evaluation Method

Fellows are evaluated by the attending physician who supervises them over the duration of the rotation. Verbal feedback is given is given on an ongoing basis. An ABIM-format evaluation is completed and reviewed with the fellow at the completion of the rotation. If an attending physician judges that a fellow is not performing adequately in any area of evaluation, he or she must explicitly provide constructive feedback sometime during the middle of the rotation.

Fellows evaluate their attending physicians and the rotation in terms of patient mix, experience as well as the number of procedures by filling in an evaluation form at the end of the rotation.