The Critical Care Medicine Fellowship is organized into required rotation blocks, elective rotations and procedural skills. Learn more about each of these rotation sections below.
Our curriculum is organized into 13 four-week rotations (blocks). All fellows complete three to four blocks in the Surgical ICU, three blocks in the Cardiovascular ICU, one block in the Neurosurgical ICU, one block in the Critical Care Medicine Unit, one block in the Emergency Critical Care Center, and one block of Critical Care Ultrasonography and Advanced Critical Care Echocardiography. The fellow is able to choose from a variety of elective rotations to fill the remaining time. These required rotations are summarized below.
The Surgical Intensive Care Unit (SICU) cares for patients with a variety of surgical issues. Fellows gain substantial experience managing intra-abdominal sepsis, liver transplantation and hepatobiliary surgery; kidney transplantation, pancreas transplantation, oral and maxillofacial surgery as well as a variety of other surgical procedures. Fellows learn to care for a diverse surgical population because although our institution has a separate Trauma and Burn ICU, trauma patients are frequently cared for in the SICU as well.
In addition to caring for a diverse surgical population, this unit is an extracorporeal membrane oxygenation (ECMO) referral center for severe respiratory failure. Therefore, while rotating in this unit, fellows also gain experience managing severe acute respiratory distress syndrome (ARDS) and other forms of respiratory failure. This includes ventilator management strategies and cannulation for ECMO support when indicated.
All continuous renal replacement therapy is managed by the ICU team, which gives our trainees expertise in the initiation and management of dialysis for renal dysfunction. In addition to the liver transplantation population mentioned previously, our fellows gain further experience managing hepatic dysfunction and coagulopathy, as the SICU uses a molecular absorbents recirculation system for treatment of severe liver failure in the SICU.
The Cardiovascular Intensive Care Unit (CVICU) provides care to critically ill patients with cardiac, thoracic and vascular surgical issues. During this rotation, fellows learn many aspects of how to manage patients before and after a variety of surgical procedures. These procedures may include coronary artery bypass grafting (CABG), cardiac valve repair/replacement using cardiopulmonary bypass and transcutaneous aortic valve replacement; aortic replacement with or without hypothermic circulatory arrest, endovascular aortic repair such as endovascular aneurysm repair (EVAR) and thoracic endovascular aneurysm repair (TEVAR) and lung transplantation; heart transplantation and ventricular assist device placement.
Patients are also admitted to the CVICU if they require a higher level of care after procedures such as pneumonectomies, pulmonary lobectomies and wedge resections, transhiatal esophagectomies or vascular bypass surgeries. Therefore, fellows learn the preoperative or nonoperative management of a variety of conditions. Finally, the fellows gain experience with the management of a variety of surgical complications such as respiratory failure, infection and renal failure.
During this rotation, fellows are continuously supervised by critical care faculty. Fellows benefit from working within a multidisciplinary team which develops their communication, leadership and teaching skills. This multidisciplinary team includes individuals from various areas of expertise including nurse practitioners, physician assistants and pharmacists; nutritionists, social workers and perfusionists; nurses and others.
The Emergency Critical Care Center (EC3) consists of five trauma bays and nine patient rooms where patients are cared for by a dedicated ICU team. The critical care fellows are integral to this team. Fellows are to be supervised by the critical care faculty and are expected to lead the EC3 team in the care of admitted patients. A primary focus of this rotation is the initial evaluation and stabilization of critically ill patients. This allows fellows to strengthen their ability to diagnose and manage a wide variety of both surgical and non-surgical disease processes.
The Neurosurgical ICU (Neuro ICU) cares for critically ill patients with neurologic and neurosurgical conditions. While on this rotation, fellows gain experience in the postoperative management of patients, such as after patients undergo surgeries including cerebral aneurysm clippings, spinal cord surgery, tumor resections and epilepsy surgery. Key skills to focus on during this rotation include:
- Indications, rationale and technique of Intracranial Pressure monitoring in the case of acute brain injury
- Stepwise management protocol for intracranial hypertension
- Fundamental troubleshooting of an external ventricular drain
- Evidence-based Emergency Department and ICU management of aneurysmal subarachnoid hemorrhage
- Evidence-based management of blood pressure in the case of intracranial hemorrhage and acute ischemic stroke
- An algorithm for management of status epilepticus
Fellows work closely with the ICU Attending to direct all critical care management. To be an integral member of this ICU team, fellows must be present Monday through Friday. Fellows therefore have weekends and holidays off during this rotation. Other expectations during this rotation include:
- Participation in neurosurgery rounds and ICU rounds, where fellows are responsible for all ICU issues that arise until sign-out with the ICU faculty
- Assistance with bedside procedures during working hours in the ICU and supervision of interns and residents performing procedures
- Instruction of interns and residents in general ICU management strategies
- In addition to didactic activities of the core program, fellows must also be present for all NeuroICU lectures
The Critical Care Medicine Unit (CCMU) is staffed by pulmonary critical care faculty. Trainees from various specialties help to care for these patients including ICU fellows from various disciplines including residents, interns and medical students as well as a multidisciplinary team of other health care providers. This experience provides the opportunity to develop skills in the diagnosis and management of problems that are less common in surgical ICUs. Some of the issues frequently encountered during this rotation include:
- Management of acute and chronic causes of respiratory failure, including advanced management of acute respiratory distress syndrome
- Experience in a variety of non-surgical conditions requiring ICU care, including: - diagnosis and management of sepsis from a variety of non-surgical causes- complications from complex/rare medical conditions especially connective tissue disorders, inflammatory conditions, immuno-suppressed states- acute and chronic causes of hepatic dysfunction- complications related to malignancies including immuno-suppression and bone marrow transplantation
- Chronic conditions that periodically worsen and require intensive therapies including chronic respiratory diseases, infections such as HIV, seizure disorders
- Acute management of toxin, alcohol and drug exposures/overdoses
- Ethical issues surrounding care of debilitated patients or those with advanced age or terminal conditions
This rotation expands upon the knowledge of echocardiography that fellows obtain during their clinical rotations. Increased competency in transesophageal echocardiography (TEE) and transthoracic echocardiography (TTE) image acquisition and interpretation are obtained through several different experiences. At least some of the fellow's time will be spent in the operating rooms conducting TEE exams before and after cardiopulmonary bypass.
A resident's remaining blocks are used to gain additional clinical experiences, to conduct research or engage in other scholarly activity relevant to critical care. Fellows are given freedom to tailor this experience based on their interests. Common choices include research, critical care nutrition, inpatient nephrology consults, inpatient infectious disease consults, respiratory therapy, ECMO, VA-SICU, and radiology.
The elective rotations (3-4 month blocks) are designed by the fellow to customize their learning experience, allowing them to focus on areas that align with their specific goals and interests. For each 1 month block, fellows can choose 1, 2, 3, or 4-week variations to best meet their career aspirations. Fellows will be given a list of electives to choose from or they can work with program leadership to design their own experiences.
While there is no requirement for fellows to complete a specific number of procedures, all of our graduates are expected to be competent at performing procedures that are essential for the practice of critical care medicine. This is accomplished through simulation and rotations, as described above. In addition to the technical skills, fellows must also learn to appropriately weigh the risks and benefits of procedures in patients with a complex array of medical and surgical conditions.
Throughout their clinical rotations, trainees gain experience with:
- Transthoracic echocardiography
- Transesophageal echocardiography and ultrasonography for vascular access
- Pleural and lung ultrasonography
- Airway management
- Invasive and noninvasive mechanical ventilation
- Percutaneous tracheostomies
- Bronchoscopy
- Thoracentesis and tube thoracostomy
- Transcutaneous and temporary transvenous pacemakers
- Pharmacologic and mechanical support of cardiogenic shock
- Use of cardiopulmonary resuscitation
- Cannulation for veno-venous and veno-arterial ECMO
- Use of technology such as rapid infuser devices for the management of massive blood loss
- Placement of arterial, central venous and pulmonary artery catheters
- Placement and management of lumbar drains
- Prescribing enteral and parenteral nutrition
- Use of multimodal approaches for analgesia and anxiolysis
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