Download pulmonary and critical care fellowship program

PULMONARY AND CRITICAL CARE
FELLOWSHIP PROGRAM
UNIVERSITY OF ARKANSAS FOR MEDICAL
SCIENCES
CENTRAL ARKANSAS VETERANS' HEALTHCARE
SYSTEM
DIVISION OF PULMONARY AND CRITICAL CARE
MEDICINE
Welcome to Pulmonary and Critical Care Medicine Fellowship at UAMS
As a Pulmonary/Critical Care Medicine Fellow, you are the first line representative for
the pulmonary consultation service and the MICU services.
In that capacity, you
represent the division and establish an image among house officers and other staff
members in the VA and University hospital. Our goal is to provide fast, courteous and
clinically relevant assistance while providing high quality education and training.
We are pleased to have you with us and have prepared this handout to offer some
guidelines and information about division functions and clinical services.
DIVISION OF PULMONARY AND CRITICAL CARE MEDICINE
KEY FACULTY
PAGER
Anderson, Paula J., M.D.
Professor of Medicine
688-6604
Bartter, Thaddeus, M.D.
Professor of Medicine
501.366.2593 phone
Erbland, Marcia L., M.D.
Professor of Medicine,
Program Director
688-6505
Johnson, Larry G. M.D.
Professor of Medicine,
688-6322
Division Director
Hiller, F. Charles M.D.
Professor of Medicine
688-6035
Joshi, Manish, M. D.
Assistant Professor of Medicine
688-6097
Mireles-Cabodevila, Eduardo, M.D.
Assistant Professor of Medicine
688-6411
Reddy, Raghu M., M.D.
Assistant Professor of Medicine
688-6290
Patel, Hiren., M.D.
Instructor of Pulmonary Medicine
688-6658
FELLOWS
Badireddi, Sridhar
688-2610
Bhaskar, Nutan
405-6745
Jagana, Rajani
688-6448
Khan, Junaid
688-2475
Meena, Nikhil Kumar
688-2130
Mohammad, Khalid
Siddiqui, Mohammad,
405-6744
688-9334
OFFICE STAFF
PHONE
A. Doris Robinson, Administrator
686-5679
Alicia Abraham, VA
257-5786
Shirley Oswald, Program Coordinator
686-5526
Cheri Baker, Administrative Assistant
686-5525
Edited - January 2012
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INTRODUCTION
The Pulmonary and Critical Care Medicine Fellowship Program at the University of
Arkansas for Medical Sciences is designed to provide a comprehensive experience in
both the clinical and research aspects of the subspecialty.
The clinical program
provides fellows with a well-rounded experience in pulmonary disease and critical care
medicine. The research program allows fellows to work under the supervision of a
faculty mentor and provides opportunities from laboratory based bench research to
clinical trials. Two-three fellows per year are accepted for a total of seven fellows.
Fellows are trained for three years, after which they are board eligible for examinations
in Pulmonary Disease and Critical Care Medicine.
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General Outline of Rotations
Year 1:
Pulm/CCM - Consults – 5 months
MICU – 3 months
Research – 3 months
Pulm
Diag/
Sleep
1
mo.
Year 2:
Pulm/CCM- Consults – 4 – 5 months
MICU – 3 months
Pulm
Rehab
1–
mo.
Research – 3-4 months
Year 3:
Pulm
CCM
Cons
0-1
mo.
MICU -5 months
(incl. VA MICU Senior fellow month*)
SICU
Trauma
1-mo.
R-hrt
Cath
Lab
research
1 – mo.
Research – 4-5 months
*VA MICU Senior Fellow month:
In the 3rd and final year of training, each fellow does a VA MICU rotation as a sort of
―junior attending‖ with an increased level of responsibility for the MICU team and for all
aspects of patient care, communication and teamwork. During this month, the fellow
independently leads morning MICU team rounds on most days, though the attending is
available if needed. The fellow is responsible for teaching during rounds and for
providing feedback to the more junior team members regarding their performances.
After ―fellow rounds‖ each day, and additionally as needed, the fellow and attending
review all the patients, plans and team performance and modify as needed.
CLINICAL PROGRAMS AND FACILITIES
The Division operates pulmonary consultation services at both the University Hospital
and the Central Arkansas Veterans’ Healthcare System. The clinical populations of
these two institutions provide a varied clinical experience, ranging from COPD and lung
cancer to interstitial lung disease, sarcoidosis, community acquired pneumonias, and a
host of opportunistic infections in immuno-compromised patients. On the consultation
services, the fellow supervises the resident or senior medical student or performs an
initial evaluation of each patient. Following a case presentation by the fellow, resident
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or student the consult attending interviews and examines the patient. The attending
staff rounds daily.
The Pulmonary/Critical Care Medicine Division provides attending staff for the MICU
teams at both the University Hospital and the VA Medical Center. These ICUs provide
a well-rounded experience in critical care medicine ranging from respiratory failure,
ARDS, septic shock, GI bleeding, acute renal failure and liver failure to critical illness in
immunocompromised patients.
The fellows provide supervision for the residents,
interns, and students. The attending staff round daily. Consultation services are freely
utilized to maximize patient care and teaching.
The Division operates a high quality pulmonary function laboratory in both institutions.
These laboratories are capable of providing diagnostic services from simple spirometry
to bronchoprovocation and exercise testing. The Division also operates a full-service
sleep laboratory.
Division conferences include a problems conference attended by Pulmonary/Critical
Care Medicine faculty and fellows representatives from Radiology and the State Health
Department, and house officers and students on the inpatient Pulmonary consult
services. At this conference, fellows, residents or students present cases. A fellow
offers an initial interpretation of the case and differential diagnosis. Faculty members
offer expert opinions. The Division also operates a weekly educational conference that
rotates between journal club, research conference, physiology conference, and critical
care grand rounds. A lung cancer conference is held biweekly at the VA and University
Hospitals to discuss case management.
DESCRIPTION OF TRAINING PROGRAM ROTATIONS AND FELLOW
RESPONSIBILITIES
UAMS MEDICAL CENTER: PULMONARY/ICU CONSULTATION SERVICE
Fellows are responsible for consultations on the Medicine and Surgical services,
including surgical subspecialties, other Critical Care Units, and Obstetrics and
Gynecology. The Consultation Service generally sees 1-5 new consults per day and
follows 5-15 patients for consultation management. The inpatient consults range from
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the treatment of acute exacerbations of COPD or asthma, community acquired
pneumonia, DVT/PE, to the diagnostic evaluation of lung nodules or masses, chronic
pneumonia, pleural effusions to acute respiratory disease in immunocompromised
patients. The fellow provides teaching and supervision to residents and medical
students who are on the consultation service. The attending physicians assigned to
this rotation supervise patient care, fellow procedures and rounds daily. The fellow and
attending physician provide appropriate didactic lessons with the house staff and
students. On the consultation service, the fellow with faculty supervision frequently
provides consultative management, to surgical, neurology and neurosurgical patients in
the ICU.
This includes ventilator management, pulmonary toilet, treatment of
pneumonia, management of fluid and electrolyte disorders and other critical care
problems. While on the consultation service, the fellow is responsible for performing
procedures under the direct supervision of an attending physician. Procedures include
flexible bronchoscopy with bronchoalveolar lavage, endobronchial or transbronchial
biopsies, transbronchial needle aspirates; chest tube insertion and pleurodesis; and
pleural biopsy. This rotation occurs in one or two-month blocks.
VAMC: PULMONARY/ICU CONSULTATION SERVICE
The fellow is responsible for supervising the consultation service, which serves the inpatient Medical and Surgical services and the out-patient 6B Diagnostic Unit. The
Consultation Service typically sees 1-7 consults per day and follows 5-15 patients for
consultation management. The attending physician assigned to this service supervises
the fellow, house staff, and/or students and conducts daily attending rounds.
The
fellow performs bronchoscopies and other procedures as indicated under the
supervision of the attending physician. The fellows and attending physician provide
appropriate didactic lessons for the house staff and students. This rotation occurs in
one or two-month blocks.
UAMS MEDICAL CENTER: CRITICAL CARE MEDICINE ROTATION
A faculty member from the Pulmonary and Critical Care Medicine Division is the
supervising attending in the MICU 12 months per year. The fellow rounds daily on the
MICU service with the MICU house staff and attending. The fellow is responsible to the
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MICU attending. During the University Hospital MICU rotation, the fellow functions as
the first line of assistance for the MICU house staff and nursing staff, for clinical and
administrative decision-making, education and procedures. The fellow rounds with the
house staff each evening to address ongoing problems. Fellows are called for all MICU
admissions and are responsible for notifying the MICU attending or the attending on
call, between 5:00 p.m. and 8:00 am. Fellows are required to be present for pulmonary
artery catheter placement and assist the house staff with other procedures, such as
tracheal intubation, central venous lines, arterial lines, thoracentesis, and ventilator
management. This rotation occurs in 1 or 2-month blocks.
VAMC: CRITICAL CARE MEDICINE ROTATION
The VA MICU is staffed by a faculty member from the Pulmonary/CCM division. The
fellow rounds daily with the MICU house staff and attending. The fellow is responsible
to the MICU attending and oversees the care of MICU patients. Fellows are called for
all admissions to the MICU and are responsible for notifying the MICU attending or the
on-call attending, between 5:00 p.m. and 8:00 am.
General Expectations of Pulmonary/CCM Trainees in the Medical ICUs
The basic premise is that fellows training in critical care are expected to participate fully
in all aspects of the provision of care to patients with critical illness. To improve fellow
involvement and training in the critical care units, the following guidelines have been
implemented for both the UAMS and CAVHS MICU’s.
Weekday MICU fellow activities
1. The weekday MICU fellow should perform a written evaluation of all MICU
admissions admitted prior to 5 PM and review the care plans with the attending
physician
2. The weekday fellow should supervise or perform all resident procedures, e.g.
intubations, central venous lines, and thoracentesis.
The fellow should also
inform the attending physician of the approximate time when such procedures
will occur so that the attending physician may also be present when feasible.
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3. The weekday MICU fellow should establish weaning plans with the attending
physician early each morning and enact them with assistance from the residents
and respiratory therapy.
4. The weekday MICU fellow should conduct brief walk-thru rounds with the
resident and weekday attending physician at the end of each workday (~5 PM).
5. The weekday MICU fellow is expected to
sign out to the on-call fellow for both
the VA and University MICU’s daily and should receive an update from the oncall fellow on events that occurred during the night on all patients prior to the
beginning of daily rounds.
Weeknight on-call fellow activities
1. The weeknight on-call fellow must come in, physically examine, and write an
evaluation on all sick admissions or existing sick patients with significant new
developments and help stabilize them regardless of the time of night.
The
definition of a sick admission or existing sick patient includes, but is not limited
to, the following: a patient with an unclear diagnosis, evidence for acute lung
injury or acute respiratory distress syndrome, severe hypotension, multisystem
organ failure, or a patient with rapidly deteriorating clinical status.
2. The weeknight fellow on call should review the status of all MICU patients in the
early evening (~9 PM) each day. This activity can be performed by phone or inperson.
Significant developments should be discussed with the attending
physician on call.
Weekend fellow activities
1. The weekend fellow will provide MICU coverage at the UAMS or VA MICU from 5
PM Friday through 7:30 AM Monday.
2. This fellow will be expected to perform a written evaluation of all patients
admitted before 5 PM on Saturday and Sunday and provide a written evaluation
of all sick admissions or existing sick patients as defined above after 5PM on
Friday, Saturday, and Sunday. The MICU fellow will generally be expected to
remain at UAMS or the VA until ~5PM on weekends, unless the MICU has an
unusually low census.
3. Each new patient must be discussed promptly with the weekend attending
physician either by phone or in person.
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4. The weekend fellow should review the status of all MICU patients with the
weekend call resident by phone or in person each evening (~9 PM) and discuss
significant changes in status with the weekend call attending physician.
The training program understands the increased hospital time that these activities will
incur.
To abate the consequences of increased hospital time, the program will
implement the following:
1. The UAMS MICU fellow who is completing weekend call will be permitted to leave
after noon conference on Monday provided an appropriate sign-out to either the
daytime consult, MICU fellow, or research fellow is performed.
2. The Division will provide cafeteria meal tickets to both weekend call fellows to cover
the cost of in-hospital meals on Saturday and Sunday.
VAMC: MICU ACTING ATTENDING
As part of the progressive curriculum, during the latter part of the third year of training,
the fellow will manage the VA ICU in the manner of an acting attending physician for
one month. The Pulmonary/Critical Care Medicine faculty member assigned to the
University Consultation Service continues to be the responsible attending and serves
as the fellow’s mentor. The fellow will supervise work rounds and lead the MICU team
teaching rounds. The fellow and supervising faculty member round together daily. It is
anticipated that by this time in the training, the fellow is fully capable of functioning as
attending physician on this service. The fellow rounds daily, from Monday to Friday
and cover the VA service 2 weekends out of the month.
PULMONARY REHABILITATION/PULMONARY FUNCTION LABORATORY
ROTATION
During this non-inpatient rotation, the fellow is versed in the physiologic principles of
pulmonary function testing, cardiopulmonary exercise testing and related testing. The
laboratories at the University Medical Center and the VA Medical Center are fully
equipped to measure all aspects of lung function and mechanics. Bronchoprovocation
studies are performed at UAMS, and cardiopulmonary exercise testing is available at
the VA. The fellow on this rotation will have didactic sessions with pulmonary function
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laboratory personnel, interpret pulmonary function tests and review these with an
attending staff, and attend VA cardiopulmonary exercise tests.
OUTPATIENT CLINICS
Fellows have continuity clinics for pulmonary patients at both the VA and the University
Hospital. Each fellow has 2 VA Clinics per month and 2 University Clinics per month;
one fellow’s clinic per week alternating between the VA and the University.
This allows follow-up of a variety of pulmonary disorders and the opportunity to
evaluate new patients with pulmonary disease. Fellows are responsible for complete
history and physical examinations of new patients and synthesis of a diagnostic and
therapeutic plan.
Fellows are also responsible for long-term follow-up and
management of patients with chronic pulmonary problems. A Pulmonary/CCM faculty
member supervises the fellows.
UAMS Continuity Clinic
The UAMS clinic is held every Wednesday of the month on the 2 nd floor of the
Ambulatory Care Clinic Building (UPMG clinic). Three fellows are assigned on the first
and third Wednesdays the remaining three fellows are assigned on the second and
fourth Wednesday.
VA Continuity Clinic
The VA fellow’s clinic is held every Tuesday of each month, in the Specialty Care II
Clinic. Three fellows are assigned the 1 st and 3rd Tuesday of the month and the
remaining 3 fellows are assigned the 2 nd and 4th Tuesday of the month. There is a bimonthly pulmonary clinic at the VAMC on Thursday afternoon; 3 fellows attend every
2nd Thursday of the month and the other 3 fellows attend every 4 th Thursday of the
month.
Cystic Fibrosis Clinic
An Adult Cystic Fibrosis Clinic is held on the last Friday of each month at University
Hospital (UPMG clinic). A fellow on research attends this clinic and is supervised by
Dr. Paula Anderson or the faculty assigned to clinic that day.
Tuberculosis Clinic
The second and third year, fellows are assigned a monthly tuberculosis clinic at the
Pulaski County Health Unit. The fellows are responsible for the evaluation and/or
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treatment of patients with suspected or proven tuberculosis. They follow the State
Department of Health protocols for the diagnosis and treatment of tuberculosis.
Problematic patients are presented to the Tuesday morning case conference at UAMS
Medical Center.
Sleep Clinic
While on research, the fellows attend 2 sleep clinics a month at the VAMC for 2 months
per year.
Outpatient Care and Record-Keeping Policies
Clinic notes
Clinic notes must be completed in a timely fashion, preferably the same day as the visit,
but no later than noon the following day. In the VA system, completion includes your
signature, since the clinic clerks cannot act upon an unsigned note. All notes must
indicate the degree of attending involvement, and the division policy is that all notes,
including no-show notes, must be cosigned by an attending.
Orders for tests
The VA uses the Provider Order Entry (POE) system, in which selected tests will not be
ordered by the clinic clerks. To arrange a CT scan or PET for a VA patient, you must
make Ms. Abraham co-signer on the note, unless you plan to order the scan yourself.
Fellows must order echocardiograms and consultations (sleep study, home oxygen)
personally.
Patient calls and related communications
One of the pulmonary fellows’ responsibilities in Continuity Clinic is to communicate
with patients, not only at the clinic visits but also as needed between visits to report test
results, outline next steps, and respond to inter-current problems as reported by the
patient.
The clinic attending physician should be the primary resource when needed in these
matters and should be sought out by the fellow for questions between scheduled clinics
as well. If the clinic attending will not be available in a timeframe which fits the
circumstances, as might occur when on leave, the fellow should seek input from either
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the attending on the Consult service of the involved institution or from the program
director.
In the VA Pulmonary Fellows Clinics, fellows are to return all patient calls personally in
a timely manner, usually within 24 hrs. The VA pulmonary secretary is not authorized
to report test results, take the patient’s history or pass along messages that the fellow
will be in touch at some unknown later time. She will simply record the date and time
that she has given the fellow the message to call the patient. In the fellow’s known
absence, such as when on leave, Ms. Abraham is authorized to ask the patient if a
callback on the expected date of return is acceptable. If the problem cannot wait until
then, and at any time it appears that a fellow has not returned the patient’s call, the call
will be referred to the clinic attending physician who was most recently involved.
There will be times when a patient calls with questions while the fellow has yet to
review test results, present a case to conference, or otherwise get some additional
information that is needed to address the questions fully. If the fellow will not have that
information within the usual call-back timeframe, it is the fellow’s responsibility to call
the patient for an interim update and make plans to talk again later. This simple
courtesy can prevent a lot of unnecessary repeat calls by patients and patient
dissatisfaction.
The fellow should place a brief note in the medical record documenting all phone calls
and updates to the treatment plan.
RESEARCH PROGRAMS AND FACILITIES
Dr. Charles Hiller came to Arkansas in 1975 and established a well-recognized group
in the area of particle interaction with the lung. Dr. Hiller was the Division Director from
1985 to 2003, and continues to practice as a faculty member.
He established the
accredited critical care program. The particle deposition program he started continues,
strengthened by the return of Dr. Paula Anderson to the faculty in 1989. Drs. Hiller and
Anderson have a large ongoing clinical trials program involving the use of inhaled
drugs in asthma or COPD.
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Dr. Paula Anderson joined the faculty in 1989 after three years at the Harvard School of
Public Health where she was involved in research using aerosols as a tool to study
lung physiology.
Dr. Anderson is former President of the International Society of
Aerosols in Medicine and is internationally known for her expertise in inhaled drug
delivery and outcomes measurements.
Dr. Anderson is involved with other faculty
members in the clinical trials program involving the use of inhaled drugs in asthma or
COPD.
She has developed a clinical trials program for experimental therapies in
patients with cystic fibrosis. Drs. Anderson and Hiller are also using a sensitive assay
to study the pharmacokinetics and pharmacodynamics of inhaled albuterol and
salmeterol.
Dr. Marcia Erbland has research interest in the area of COPD, including pulmonary
physiology and nutrition, and the interface between intensive care medicine and
palliative care. She has been the Principle Investigator of a VA Cooperative study,
―Systemic corticosteroids in COPD exacerbations‖.
With support from the Central
Office VA Cooperative Studies Program in the form of a planning grant and support
personnel, Dr. Erbland assembled a committee of national experts in COPD and
prepared a complete protocol for a randomized double blind, placebo controlled trial of
methylprednisolone and prednisone in the management of patients hospitalized with
acute exacerbations of COPD.
FELLOW CALL SCHEDULES
At all times, there is a fellow on call for the clinical services at each hospital. Between
5:00 PM and 8:00 AM Monday – Thursday, there is one fellow on call for both
institutions (weekday, night call 1 in 6). From Friday 5:00 PM until Monday 8:00 AM
one fellow is assigned to each institution (weekend call 1 in 3). In general, the fellow
on service takes calls during the day (8:00 AM to 5:00 PM) Monday through Friday and
is responsible for attending daily rounds. The on-call fellow is notified of all MICU
admissions at night and on weekends and is responsible for notifying the attending
physician or the on-call physician.
The fellow on service signs out with the on-call
fellow at the end of each day and prior to the weekend. Likewise, the on-call fellow
informs the fellow on service of significant events during their time on call.
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Changes in weekend coverage should be clearly agreed to by both parties well in
advance and attendings informed.
Fellows are expected to handle their own
―swapping‖.
Referral calls at University Hospital are handled by a faculty member between 8:00 AM
and 5:00 PM and by the on-call fellow between 5:00 PM and 8:00 AM. The fellows
should discuss problematic and/or sensitive referrals or transfers with the on-call
physician.
Fellows are expected to document patient calls, so that the relevant
information can be forwarded to the clinic records.
DIVISION MEETINGS & CONFERENCES
Fellows are expected to attend all of the required conferences when not on vacation,
sick leave, or directly caring for a patient in an emergency. If the latter, the fellow
should communicate the reason for the absence with the attending of the service
before or after the conference. Any absences that do not fit one of the above categories
will be considered unexcused absences, which interfere with the educational process.
An overall attendance rate below 85% in any of the conferences in any academic year
(attendance will be counted on an annual basis for each individual conference) will be
considered unsatisfactory.
PULMONARY/CCM Noon CONFERENCE
Monday 12:15 PM to 1:15 PM VA 6B/117 Conference Room
This conference rotates between Basic Science, Critical Care, Research and Journal
Club.
It is held at the VA Hospital in the conference room on 6B.
Clinical Case
Presentations are used to present a focused discussion of Critical Care and Basic
Science Core Conference topics. For journal club, there is a focused discussion of a
topic based on 1-3 papers from scientific journals. When preparing a conference talk,
fellows should identify a faculty mentor and review the topic and planned talk. Fellows
are required to forward a copy of their core conferences (slides, handouts and/or
overheads) with a reference list to the program coordinator for filing in the core
conference reference library.
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CHEST MEDICINE CONFERENCE
Every Tuesday of the month; 8:00 AM to 9:00 AM; UAMS - Diner Learning Center –
Conference Room M1/252
This is a case-based x-ray conference attended by division members, and staff from the
state health department, and radiology.
The conference is held in the Radiology
conference room at the University Hospital. A fellow or faculty member is assigned
each week to present interesting cases and problem cases from both institutions. Each
presentation should include a short didactic session illustrated by one or more of the
cases presented. Fellows unfamiliar with the cases are asked to interpret the films, give
a differential diagnosis and propose a diagnostic or therapeutic plan. UAMS
radiographs are accessed via the Sectra digital system in the conference room. VA
radiographs are presented from CD’s; the presenter must provide the patient
information and radiology case # to VA Radiology department in advance to have these
prepared.
MONTHLY FELLOWS’ RESEARCH MEETING
4TH Wednesday of every month at 12:00pm to 1:00pm; UAMS Ebert Library
All fellows + Dr. Johnson and Drs. Erbland and/or Mireles and other faculty meet the 4th
Wednesday of each month 12:00-1:00pm, in the Ebert Library
Format: Each fellow will spend a few minutes giving an update on his/her research and
other scholarly activity with fellow and faculty feedback on how to make further
progress.
Discussions may include how to get started, potential research
questions/projects, progress to date (brief), roadblocks and how to overcome them.
Detailed presentation of results, data, ATS poster/slideshow/practice will usually be
targeted for a regular division conference time.
MONTHLY FELLOWS MEETING
3th Tuesday of every month at 12:00 PM to 1:00 PM; VA Pulmonary Conference
Room
Dr. Erbland meets once a month with the fellows for announcements and feedback.
Combined VA –UAMS Lung Cancer Conference
The Multidisciplinary Lung Cancer Conference is held every Thursday from 4-5 pm in
the ACRC 5th floor conference room.
Fellows on either consult service—VA and
UAMS—are expected to attend and to present cases, including bronchoscopy findings.
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VA cases for presentation should be turned in to the VA pulmonary secretary by noon
on Tuesday.
OTHER CONFERENCES:
MEDICINE GRAND ROUNDS
Medicine Grand Rounds occur in Education II Building Room G141 every Thursday at
noon.
Fellows should regularly attend Medicine Grand Rounds. Grand Rounds
contributes to the total yearly P/CCM Core Conferences. In any given year, one-third or
more of Grand Rounds topics are highly relevant to the P/CCM curriculum. Fellows are
expected to make every effort to attend Medical Grand Rounds, especially those that
are closely aligned with our curriculum, and should help organize the clinical services
to make this possible. It is requested that you silence your pager and cell phone during
the meetings.
The fellows are expected to be present and on time for these meetings. Fellows
on research rotation are to attend conferences as usual unless leave has been
requested in advance.
Fellow’s Quality Improvement Project
In an effort to provide educational experiences in systems-based learning, each fellow
will be required to complete at least 1 quality improvement (QI) project during their
pulmonary fellowship. These projects may be conceived by the fellow or assigned by a
pulmonary faculty member. The program director will determine whether an activity is
appropriate for consideration as a QI project. Depending on the scope of the project,
the quality of project report, and the degree of competence demonstrated by the fellow,
completion of more than one project may be needed to fulfill this learning requirement.
Each project must have an identified pulmonary faculty member to mentor the process.
Ideas for PI projects often arise in the course of patient care encounters, reviews of
current literature, working with electronic charting and data systems, conference
discussions. The typical project might involve increasing the use of evidence-based or
consensus-based medical management, addressing patient safety or problem-prone
issues, or improving fellow education, in a way that makes use of existing systems
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and/or creates new or improved systems and involves persons from more than one
department or discipline.
Once a project is selected, the fellow will assist the faculty member in selecting
members of a team that will work together in addressing the problem. The teams
should be multi-disciplinary and include representatives appropriate for the problem
addressed. It is possible to include more than one pulmonary fellow on the team. The
fellow will often serve as team leader, but may defer this to another team member. The
fellow must, however, be active in the team’s functioning. The fellow and attending will
usually determine the meeting schedule.
Teams will then begin to analyze the problem, consider possible solutions, implement
changes, and assess the impact of those changes. This may require further refinement
depending on the results. Once the team has agreed to complete its work, the fellow
will complete a report on the efforts of the team and submit it to the program director.
The work will also be presented at one of the fellow’s quality improvement conferences.
At the program director’s discretion, departmental or institutional committee
participation may count toward the completion of this requirement.
The fellow’s
experience on the committee must then be summarized in a report to the program
director and reported on at the QI conference.
Fellows will discuss progress toward completing this QI project with the program
director at their regular one-on-one meeting. If any problems arise in the completion of
this, the program director will serve as the final arbitrator.
PROCEDURE LOGS
When you complete your training in our program, it will be essential for you to have an
accurate log of the procedures you have performed. This may be necessary for board
examinations or obtaining hospital privileges. Through UAMS the fellows have access
to a web-based computerized procedure database (New Innovations; www.newinnov.com). The fellow must record required procedures (see attached list) on New
Innovations and request confirmation by the supervising attending physician. At the
end of each academic year in June the fellows will receive a list of their procedures.
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FELLOW AND FACULTY EVALUATIONS
At the end of each rotation, each faculty member who supervised the fellow during that
rotation completes an evaluation; New Innovations, www.new-innov.com - see attached
form.
The fellows are evaluated with respect to the standard 6 competencies and
Pulmonary/Critical Care Medicine procedures. The faculty and fellows should discuss
these evaluations face-to-face at the end of each rotation and discuss any areas that
need attention or remediation. The Fellowship Education Committee meets on a semiannual basis to review these forms. The Division or Program Director meets every 6
months with each fellow and reviews his/her progress based on the evaluations, the
committee’s comments, and his/her own assessment. A written summary is placed in
the fellow’s file.
At the end of each rotation the fellows complete evaluations of their supervising faculty.
The evaluations are anonymous and are reviewed annually by the Division Director.
The Division Director provides feedback from the fellow’s evaluations to the individual
faculty member at the time of their annual faculty review.
In June, the fellows present critique of the fellowship program’s strengths, and
weaknesses, with suggestions for improvement.
The Graduate Medical Education
Committee conducts a mandatory computerized Program Evaluation every year.
The Fellowship Education Committee is comprised of the Program Director, one or two
faculty members and a fellow. Current faculty members are Drs. Erbland, Johnson and
Mireles. This committee meets semi-annually and at other specially scheduled times if
necessary, to discuss program content, problems and remedies.
Straightforward
issues are discussed at the monthly faculty meetings. Difficult issues are discussed
promptly with the Division Director. Faculty may also independently forward comments
or suggestions to the program director.
Fellows meet monthly as a group with the Program Director.
The purpose of this
meeting is to deal with problems relevant to the training program. The problems may
be relatively minor, such as scheduling, to more significant problems such as program
content. This is an ongoing process and serves to provide continuous feed back for
18
the program director. In addition, the fellows meet individually with the director every 6
months for review of their progress.
The training program has general guidelines for the number of procedures considered
necessary for achieving competency.
In addition ―competency‖ is based on direct
observation of the fellow by the supervising faculty. The faculty evaluates the
procedural skills of the individual fellow during their clinical rotations (see fellow’s
evaluation form). The faculty base on their direct observations is indeed sufficiently
competent.
MOONLIGHTING
The Fellows may moonlight with the written permission of the Program Director. It is
imperative that moonlighting not interfere with the fellow’s clinical duties and
responsibilities, conference quality or scholarly output or exceed the 80-hour workweek
rule. Moonlighting for the VA (internal moonlighting) counts toward the 80-hour work
week. Fellows are prohibited from moonlighting while taking night or weekend call. The
Divisional Policy on Moonlighting is attached.
PROFESSIONAL MEETINGS
A primary goal of this Pulmonary/Critical Care Medicine fellowship is for the fellows to
conduct fruitful research. The ultimate goal is for the fellow to write a manuscript and
have it accepted for publication in a peer-reviewed journal. Every fellow should, during
the fellowship, identify a research project and mentor, generate original data, write an
abstract, present the data as a poster or a talk at a national meeting (e.g. ATS, ACCP
or ASCCM). The division will support the cost of a fellow attending a professional
meeting if a poster or paper is presented.
19
There are conferences for fellows in conjunction with the ATS and ACCP annual
meetings. Usually each fellow will have an opportunity to attend at least one of these
conferences during their fellowship, especially if outside funds are available. Priority is
given to conferences at which the fellow is presenting scholarly work or to acknowledge
such work.
Attendance to professional meetings by fellows wishing to pay their own way is
acceptable if coverage is provided and approved in advance.
VACATION AND SICK LEAVE POLICY
Vacation:
Fellows receive 21 days of vacation (15 weekdays and 6 weekend days) of paid
vacation each year, which cannot be carried over from one year to the next.
All
requests for vacation must be accompanied by a completed leave request form. Prior to
approval, fellows must work with the chief fellow to arrange coverage for services and
call while on vacation.
period.
No more than 2 fellows can be on leave during the same time
During any one academic year, the fellow may take one week of vacation
during a clinical rotation; remaining vacation must be taken during research or elective
months. Vacation during a clinical rotation must be done as a single 1-week block and
requires pre-approval by the attending on the clinical service before approval by the
PD. Appropriate coverage must be arranged and must not cause an undue amount of
disruption in continuity of care on service, e.g., coverage generally provided by a single
fellow for the block (excluding weekends).
Sick Leave
Fellows receive 12 days of sick leave. If sick leave is taken while on clinical service,
fellows should, to the degree possible by the circumstances, be involved in arranging
coverage and should communicate with both the Program Coordinator and the involved
attending.
Educational Leave:
Educational leave, not to be counted against vacation time, is available for selected
activities such as time spent taking board exams or attending certain approved
conferences. Top priority is given to conferences at which the fellow will make a
20
research/scholarly presentation (e.g., abstract, poster, case presentation). All
educational leave is subject to the approval of the program director. The fellow must
make coverage arrangements as usual.
Medical Leave
Fellows have twelve days of sick leave (including weekend days) for medical reasons
during each year of training. Sick leave cannot be ―carried over‖. Sick leave in excess
of twelve days requires special review by the Assistant Dean and Program Director.
Family Medical Leave (paid and un-paid) may be granted to care for a newborn child or
seriously ill spouse, child or parent.
If unable to come in for work due to illness, the fellow should notify the PC as soon as
possible. If on an inpatient rotation, the fellow should speak in person with the
attending physician for the service. If the nature of the illness allows, the fellow is
expected to arrange coverage for rounds, clinics or other responsibilities.
Leave Request Process:
A uniform leave request form is in use for all requests and must be submitted through
the Program Coordinator (Ms. Oswald) regardless of the rotation or hospital
assignment. The Program Coordinator will notify the relevant payroll, office and clinic
staff as appropriate for the rotation. All clinical service days, clinics, conferences and
other duties must be accounted for on the leave request by appropriate coverage and,
in the case of clinics, cancellation well in advance. All vacation leave requests should
be complete and available for the program director’s signature 2
months prior to the
proposed leave. It is a goal to identify vacation times enough in advance so that clinics
can be cancelled without major rescheduling of patients.
Sick leave requests should
be turned in to the PC at the first opportunity.
Attendance
Fellows are expected to be at work daily and at all required conferences whether on a
clinical, research, or elective rotation, unless on vacation or other leave or, in the case
of conferences, has an excused absence, which includes vacation, leave, and patient
emergencies. ―At work‖ means on campus and readily available by pager, including
while on research rotations and electives. Absence from conference is considered
21
unexcused unless one of the approved reasons is on file with the Program Coordinator.
The fellow is responsible for seeing that this information is on file, i.e., the office will not
be required to cross-check your absences with your leave records.
OTHER POLICIES
Other policies of the Graduate Medical Education Committee are available in the
UAMS-COM Resident Handbook at http://www.uams.edu/gme/toc.htm.
BOOK FUND
Each fellow is allotted a yearly book stipend (typically $300 per year) for the purchase
of books or other educational material.
Requests should be made through Doris
Robinson in the UAMS Pulmonary Office. Any book funds not spent in the current year
will not be allowed to be carried forward to the next year. Book Fund may be used for
fees, dues, board exam fees or meetings.
CHRISTMAS PARTY COVERAGE
It is tradition in the Department of Internal Medicine for the first-year Pulmonary/Critical
Care fellows to cover the MICUs at the VA and at UAMS on the night of the annual
Medicine Christmas party so that the house staff may attend. This is mandatory for the
first year fellows and the only exception would be if they arrange coverage by another
Pulmonary/Critical Care fellow.
22
PULMONARY STAFF
NAME
FACULTY
PAGER #
TELEPHONE
688-6604
686-5525
UAMS 3S14c
Bartter, Thaddeus
366-2593
UAMS Barton 4R/29
Bartter, Teka
410-0551
Anderson, Paula
FAX
686-7893
OFFICE LOCATION
SLOT#
555
555
555
Erbland, Marcia
688-6505
257-5786
LRVA 5A105
VA-111-P
Hiller, F. Charles
688-6035
686-5525
UAMS Barton 4R/10
555
Johnson, Larry G
688-6322
686-6559
UAMS3S/14
555
Joshi, Manish
688-6497
257-5786
LRVA 5A103
VA-111-P
Mireles-Cabodevila, Eduardo
688-6411
686-5525
UAMS 3S14d
555
Reddy, Raghu M.
688-6290
257-5786
LRVA 5A102A
VA-111-P
688-6658
257-5786
686-5525
LRVA 6A132A
VA-111-P
555
Patil, Hiren V.
FELLOWS
686-7893
Badireddi, Sridhar
688-2610
686-5525
UAMS3S14g
555
Bhaskar, Nutan
405-6745
686-5525
UAMS 3S14g
555
Jagana, Rajani
688-6448
686-5525
UAMS 3S14g
555
Khan, Junaid
688-2475
686-5525
UAMS 3S14g
555
Meena, Nikhil Kumar
688-2130
686-5525
UAMS3s14G
555
Mohammad< Khalid
405-6744
686-5525
UAMS 3s14g
555
Siddiqui, Mohammad F
OFFICE STAFF
688-9334
686-5525
UAMS 3s14g
555
555
686-7893
Robinson, A. Doris
686-5679
UAMS 3S14
Oswald, Shirley
686-5526
UAMS 3S14
Baker, Cher ([email protected])
686-5525
UAMS3S14
Abraham, Alicia (VA)
257-5786
257-5787
LRVA 5C/144
VA111-P
Shaw, Cyndi – Stukenburg, Al
PFT LAB
257-5866
257-5867
LRVA 6a/116
111-LR
555
686-5149
296-1126
Barton 4R08
Hicks, Kathy: Inpt PFT & Special Procedures
686-5148
686-5976
UAMS 3D26
593
Melton, Paula – Thompson Jennifer – Out pt
686-5384
UAMS 3D26
593
Burrow, Vanessa – VA PFT Lab
BRONCOSCOPY
257-5634
686-6407
LRVA 5A/102
Taggart, Adam
416-7019 cell #
Kagebein, Susie – UAMS
688-2834
Broncoscopy Lab RM # 1
870-830-6787
526-8817
Jenkins, Peggy – VA
ACRC
257-1000x55827
Jones, Shirley A.
526-6990X8702
SLEEP LAB
Carmical, Paul W.
257-6064
Shelton, Judith
OUTPATIENT CLINIC
257-6064
296-1181
257-6063
ACRC 7th Floor
LRVA 7C/110
LRVA 7C/110
603-1480
547-15
Bishop, Doris
296-1170, 1245
Outpatient Clinic 2H
Jackson, Donna
296-1170, 1244
Outpatient Clinic 2H
Hurley, Melissa – Point of Service Coordinator
296-1170, 1214
Outpatient Clinic 2H
Newton, Melanie – Medical Assistant
MEDICAL RECORDS
296-1170, 1246
686-6038
TB Clinic
Bates, Joseph
Patil, Naveen
280-3110/ 3111
N/A
721-2
524
280-3180
661-2398
AR Dept of Health
661-2152
AR Dept of Health
23
CURRICULUM
PULMONARY CONSULTATION ROTATION
OVERVIEW AND GOALS
Pulmonary medicine encompasses a broad range of disorders involving the lungs,
airways, pleura and chest walls. The pulmonary specialist has expertise in neoplastic,
inflammatory, and infectious disorders of the lung parenchyma, pleura, and airways;
pulmonary vascular disease and its effect on the cardiovascular system; and detection
and prevention of occupational and environmental causes of lung disease. Due to the
life-threatening nature of acute respiratory failure, and the physiology involved in
providing mechanical ventilatory support, a strong link between pulmonary medicine
and multidisciplinary critical care medicine has developed.
Evaluations and
management of sleep-disordered breathing is also associated with the general area of
pulmonary medicine. The goal of the Pulmonary Medicine rotation is to provide prompt
and relevant subspecialty consultation for patients with lung disease. This evaluation
includes
a
comprehensive
history
and
physical
examination
with
specific
recommendations for further diagnostic tests and/or treatments.
24
EDUCATIONAL CONTENT, INCLUDING THE MIX OF DISEASES,
PATIENT CHARACTERISTICS, TYPES OF CLINICAL ENCOUNTERS,
PROCEDURES, AND SERVICES
The Division operates Pulmonary Consultation services at both the University Hospital
and the VA Medical Center. The combined clinical populations of these two institutions
provide a varied clinical experience, ranging from COPD and lung cancer to interstitial
lung diseases, sarcoidosis, community acquired pneumonias, and a host of
opportunistic lung infections in immuno-compromised patients. Both institutions serve
as referral centers for the state of Arkansas. There is an active Medical Oncology
service and a large peripheral blood stem cell transplant (focused on Multiple
Myeloma) program at the University Hospital. These services provide a good exposure
to pulmonary malignancies (primary and metastatic), treatment related lung toxicity and
opportunistic lung infections. The University Hospital has active general surgical,
neurosurgical, cardiothoracic, and vascular surgery services and a high-risk obstetrics
service, which frequently request pulmonary surgery consults. The VA Medical Center
has one of the largest VA Medicine services in the country and presents an excellent
exposure to common lung diseases, such as COPD, asthma, pneumonia and lung
cancer.
The Pulmonary Consultation Services at both institutions offers ample
opportunities for invasive procedures utilized in Pulmonary Medicine.
PRINCIPAL ANCILLARY EDUCATION MATERIALS USED
(X) Reading from recommended text
(X) Radiological studies
(X) Pathologic Materials
(X) Other noninvasive studies
(X) Handouts on relevant topics
(X) Articles from the core literature
(X) Computer-based learning
(X) Case studies
(X) Board Review questions
(X) Other: __________________
FELLOW RESPONSIBILITIES
25
UAMS MEDICAL CENTER: PULMONARY/CCM CONSULT ROTATION
Fellows are responsible for consultation on the General Medicine and Surgical
services, including surgical subspecialties, other Critical Care Units, and Obstetrics
and Gynecology. The Consultation Service generally sees 1-5 new consults daily and
follows 5-15 patients in daily consultation management. The fellow provides teaching
and supervision to residents and medical students assigned to the consultation service.
The attending physician supervises all patient care and fellow activities and conducts
daily rounds.
The fellow and attending physician provide didactic lectures for the
housestaff and students assigned to the consult service.
The fellow, with faculty
supervision, commonly provides consultative management, (e.g. mechanical ventilator
management; pulmonary toilet; treatment of pneumonia, fluid and electrolyte disorders
and other critical care problems) for critically ill patients in the University ICU on nonMedicine Services (i.e. surgery, neurology, or neurosurgery).
The fellow on the consultation service is responsible for performing procedures such as
flexible bronchoscopy (bronchoalveolar lavage, endobronchial, transbronchial biopsies,
or transbronchial needle aspirates), chest tube insertions and pleurodesis, or pleural
biopsy.
Fellows perform bronchoscopies with direct on-site supervision by the
attending physician. Attending supervision of chest tube insertion and closed pleural
biopsy is encouraged.
VAMC: PULMONARY/CCM CONSULTS ROTATION
The fellow is responsible for directing, with faculty supervision, the VA consultation
service. The major source of patients is the inpatient Medical and Surgical Services
and the outpatient 6B Diagnostic unit. This service typically sees from 1 – 7 consults
per day and follows 5 – 15 patients for consultation management.
The fellow is
expected to evaluate consult patients to ensure timely service and clinically relevant
service. The fellow performs bronchoscopies and other procedures under the direct
supervision of the attending physician. The fellow oversees the medicine residents,
residents from other services and medical students who are serving on the pulmonary
consultation service. The attending physician assigned to this service supervises the
fellow, residents and medical students and conducts daily attending rounds. The fellow
26
and attending physician provide appropriate didactic lessons for the other members,
(residents and medicine student) of the Pulmonary consult service.
METHODS USED TO EVALUATE THE FELLOW/ATTENDING/PROGRAM
Formal evaluations (6 competencies and procedural skills) of the fellows are performed
at the end of each monthly rotation by the supervising pulmonary attendings (New
Innovations; see attached). Verbal feedback from the attendings to individual fellows
takes place during the rotations. At the end of each monthly rotation, there is also
opportunity for the fellow to formally evaluate the attending physicians (New
Innovations; see attached). The consultation rotations are evaluated informally in the
monthly fellows’ meeting and the Education Committee reviews program content on an
annual basis. The program director supplies feedback regarding the strengths and
weaknesses of the two consult services to members of the Pulmonary/CCM Division at
the monthly faculty meeting.
The fellows are evaluated on their ability to appropriately perform the 6 clinical
competencies listed below at their level of training.
PATIENT CARE:
The fellow provides compassionate care that is effective for the
promotion of health, prevention, treatment, and at the end of life.
MEDICAL JUDGMENT:
The fellow demonstrates knowledge of biomedical, clinical
and social sciences and applies that knowledge effectively to patient care.
PRACTICE BASED LEARNING AND IMPROVEMENT: The Fellow uses evidence
and methods to investigate, evaluate and improve his/her patient care practices.
COMMUNICATION AND INTERPERSONAL SKILLS:
The fellow maintains these
skills and maintains professional and therapeutic relationships with patients and the
Health Care Team.
27
PROFESSIONALISM: The fellow demonstrates behavior that reflects an ongoing
commitment to continuous professional development, ethical practice, sensitivity to
diversity and responsible attitudes.
SYSTEM BASED PRACTICE:
The fellow demonstrates both an understanding of
the context and systems in which health care is provided and applies this knowledge to
improve and optimize health care.
PROCEDURAL SKILLS: Mastery of the diagnostic and/or therapeutic procedures
relevant to the practice of Pulmonary/CCM is a central goal for the University and VA
consult rotations. This includes the ability to perform the necessary manual skills, in
depth knowledge of the indications and contraindications for a procedure, know and be
able to anticipate the complications for a procedure, understand the appropriate
management for procedure related complications, and the ability to interpret the results
of diagnostic tests.
1.
Flexible bronchoscopy (overall)
a. BAL
b. TBBx
c. TBNA
2. Transthoracic needle aspiration
3. Thoracentesis
4. Close tube thoracostomy
5. Percutaneous pleural biopsy
6. Right heart catheterization
7. Central venous catheterization
8. Arterial catheterization
9. Hemodynamic monitoring
10. Pulmonary function testing
11. Cardiopulmonary resuscitation
12. Airway establishment and maintenance
13. Tracheal Intubation
a. Laryngoscope
b. Flexible bronchoscope
28
14. Mechanical ventilatory support
15. Noninvasive ventilation
16. Respiratory care
17. Interpretation of studies
SCHOLARSHIP AND TEACHING SKILLS: Curiosity, evidence of outside reading,
quality and amount of time spent in teaching students and residents.
PRINCIPLE TEACHING METHODS USED DURING THIS ROTATION:
(X) Attending teaching rounds
(X) Interdisciplinary rounds
(X) Patient management discussion
(X) Small group discussion
(X) Conferences specific to rotation
(X) Bedside clinical rounds
(X) Individual instruction of procedures
(X) Review of diagnostic studies
(X) Computer-based learning
( ) Other: ________________
PROGRESSIVE EDUCATIONAL OPPORTUNITIES
The fellow will be assigned to the University or VA consultation service for 1 – 2 month
blocks during the 3 years of fellowship training. The fellows are closely supervised by
the attending faculty with respect to patient evaluation, treatment plans, clinical
decision-making, and invasive procedures.
The fellows are allowed increased
autonomy as they progress through their training.
STRENGTHS AND LIMITATIONS SPECIFIC TO THE RESOURCES OF THE
SPONSORING INSTITUTIONS
The Consultation services provide exposure to a wide range of pulmonary diseases.
The physical facilities are excellent and both institutions have a complete complement
of support services as well as state-of-the-art pulmonary function labs and endoscopy
suites.
PULMONARY MEDICINE
Self-Directed Learning Curriculum (Up-to-Date)
(*Indicated reference other than Up-to-Date)
(Bold indicated required)
29
Name:__________________________________
Date Completed
Asthma
1. Definition; diagnostic criteria; and prevalence of asthma
__/__/__
2. Pathogenesis and management of status asthmaticus
__/__/__
3. Overview of the management of asthma according to severity
categories
__/__/__
4. What do patients need to know about their asthma?
__/__/__
5. Diagnosis of wheezing illnesses other than asthma
__/__/__
6. Overview of occupational asthma
__/__/__
7. Reactive airways dysfunction syndrome and irritant-induced
asthma
__/__/__
8. Exercise-induced bronchoconstriction
__/__/__
9. Paradoxical vocal cord motion
__/__/__
10. Allergic bronchopulmonary aspergillosis
__/__/__
11. Metered dose inhaler techniques
__/__/__
12. Canadian asthma guidelines
__/__/__
13. NAEPP Expert Panel Report II:
__/__/__
14. Viral-induced wheezing and asthma
__/__/__
15. Peak expiratory flow rate monitoring in asthma
__/__/__
16. Use of pulmonary function testing in the diagnosis of asthma
__/__/__
17. Use of the history in the diagnosis and management of asthma
__/__/__
18. Gastroesophageal reflux and asthma
__/__/__
19. Glucocorticoid-resistant asthma
__/__/__
20. Pregnancy in patients with asthma
__/__/__
30
21. Management of theophylline intoxication
__/__/__
22. Immunotherapy in the treatment of asthma
__/__/__
23. Determinants of corticosteroid dosing
__/__/__
Bronchoscopy
1. Flexible bronchoscopic equipment and procedures
__/__/__
2. Basic principles and technique of bronchoalveolar lavage
__/__/__
3. Overview o bronchoscopy
__/__/__
4. Transbronchial needle aspiration
__/__/__
5. Bronchoscopic laser resection
__/__/__
6. Airway stents
__/__/__
7. Endobronchial brachytherapy
__/__/__
8. Rigid bronchoscopy: History and current instrumentation
__/__/__
9. Rigid bronchoscopy: Intubation techniques
__/__/__
10. An overview of medical thoracoscopy
__/__/__
COPD
1. Overview of management of stable chronic obstructive pulmonary
disease
__/__/__
2. Overview of management of acute exacerbations of chronic obstructive
pulmonary disease
__/__/__
3. Global initiative for COPD
__/__/__
4. Systemic corticosteroids in chronic obstructive pulmonary disease
__/__/__
5. Role of inhaled corticosteroids in chronic obstructive pulmonary disease
__/__/__
6. Respiratory muscle training and resting in chronic obstructive pulmonary
disease
__/__/__
31
7. Overview of smoking cessation
__/__/__
8. Clinical manifestations and natural history of alpha-1-antitrypsin
deficiency
__/__/__
9. Treatment of alpha-1-antitrypsin deficiency
__/__/__
10. Arrhythmias in chronic obstructive pulmonary disease
__/__/__
11. Transtracheal oxygen therapy
__/__/__
12. Role of mucolytic agents in the treatment of COPD
__/__/__
13. Role of methylxanthines in the treatment of COPD
__/__/__
14. Guidelines for long-term supplemental oxygen therapy
__/__/__
15. ATS guidelines: Lung volume reduction surgery
__/__/__
16. Traveling with oxygen aboard commercial air carriers
__/__/__
Cystic Fibrosis
1. Clinical manifestations and diagnosis of cystic fibrosis
__/__/__
2. Treatment of cystic fibrosis lung disease
__/__/__
3. Genetics and pathogenesis of cystic fibrosis
__/__/__
Hemoptysis
1. Etiology and evaluation of hemoptysis
__/__/__
2. Diagnostic approach to massive hemoptysis
__/__/__
3. The diffuse alveolar hemorrhage syndromes
__/__/__
4. Acute glomerulonephritis and pulmonary hemorrhage
__/__/__
32
5. Pathogenesis and diagnosis of anti-GBM antibody disease
(Goodpasture’s syndrome)
__/__/__
Interstitial Lung Disease
1. Approach to the adult with interstitial lung disease
__/__/__
2. Pathologic classifications of idiopathic interstitial pneumonias
__/__/__
3. The role of lung biopsy in the diagnosis of interstitial lung disease
__/__/__
4. ATS guidelines: Idiopathic pulmonary fibrosis: diagnosis and treatment
__/__/__
5. Asbestosis
__/__/__
6. Cryptogenic organizing pneumonitis
__/__/__
7. Diffuse panbronchiolitis
__/__/__
8. Foreign body granulomatosis
__/__/__
9. Idiopathic acute eosinophilic pneumonia
__/__/__
10. Idiopathic pulmonary hemosiderosis
__/__/__
11. Interstitial pneumonitis in HIV-infected patients
__/__/__
12. Pulmonary alveolar proteinosis
__/__/__
13. Pulmonary lymphangioleiomyomatosis
__/__/__
14. Radiation-induced lung injury
15. Pulmonary Langerhans cell histiocytosis
__/__/__
__/__/__
16. Treatment of Wegener’s granulomatosis and microscopic polyangiitis
__/__/__
17. Churg-Strauss syndrome (allergic granulomatosis and angiitis)
__/__/__
18. Interstitial lung disease in rheumatoid arthritis
__/__/__
19. Overview of lung disease associated with rheumatoid arthritis
__/__/__
20. Pulmonary involvement in Wegener’s granulomatosis
__/__/__
21. Pulmonary manifestations of systemic lupus erythematosus in adults
__/__/__
33
22. Amiodarone pulmonary toxicity
__/__/__
23. Bleomycin-induced lung injury
__/__/__
24. Busulfan-induced pulmonary injury
__/__/__
25. Chlorambucil-induced pulmonary injury
__/__/__
26. Cyclophosphamide pulmonary toxicity
__/__/__
27. Drug-induced lung disease in rheumatoid arthritis
__/__/__
28. Pulmonary disease induced by cardiovascular drugs
__/__/__
29. Paclitaxel (Taxol) Pulmonary toxicity
__/__/__
30. Methotrexate-induced pulmonary injury
__/__/__
31. Nitrofurantoin-induced pulmonary injury
__/__/__
32. Classification and clinical manifestations of hypersensitivity pneumonitis
(extrinsic allergic alveolitis)
__/__/__
33. Treatment and prognosis of hypersensitivity pneumonitis
(extrinsic allergic alveolitis)
__/__/__
Lung Cancer
1. Overview and clinical manifestations of lung cancer
__/__/__
2. ATS guidelines: Pretreatment evaluation of non-small cell lung cancer
__/__/__
3. Pathobiology and staging of small cell carcinoma of the lung
__/__/__
4. Pathology of lung malignancies
__/__/__
5. Preoperative evaluation for lung resection
__/__/__
6. Management of malignant Pleural effusions
__/__/__
7. Overview of the management of central airway obstruction
__/__/__
8. Computer tomographic and positron emission tomographic scanning of
pulmonary nodules
9. Overview of non-small cell lung cancer staging
__/__/__
__/__/__
34
10. Screening for lung cancer
__/__/__
11. Use of imaging studies in the staging of lung cancer
__/__/__
12. Clinical presentation and staging of malignant mesothelioma
__/__/__
13. Molecular markers in non-small cell lung cancer
__/__/__
14. Pancoast’s syndrome and superior (pulmonary) sulcus tumor
__/__/__
15. Treatment of small cell carcinoma of the lung
__/__/__
16. Sequelae and complications of pneumonectomy
__/__/__
Lung Transplantation
1. Indications: selection of recipients; and choice of procedure for lung
transplantation
__/__/__
2. Overview and outcomes of lung transplantation
__/__/__
3. Immunosuppression following lung transplantation
__/__/__
4. ATS guidelines: International guidelines for the selection of lung
transplant candidates
__/__/__
5. Pharmacology and side effects of cyclosporine and tacrolimus
__/__/__
6. Procedure and postoperative management in lung transplantation
__/__/__
Mechanical Ventilation
1. Physiologic and pathophysiologic consequences of positive pressure
ventilation
2. Mechanical ventilation in adults with statue asthmaticus
__/__/__
__/__/__
3. Noninvasive positive pressure ventilation in acute respiratory
failure
__/__/__
35
4. Mechanical ventilation in acute respiratory failure complicating
chronic obstructive pulmonary disease
__/__/__
5. Tracheostomy
__/__/__
Miscellaneous Lung Diseases
Diagnosis and Evaluation
1. Approach to the patient with dyspnea
2. Evaluation of chronic cough
__/__/__
__/__/__
3. Causes and diagnosis of bilateral and unilateral diaphragmatic
paralysis
__/__/__
4. Evaluation of preoperative pulmonary risk
__/__/__
5. Evaluation of pulmonary disability
__/__/__
6. Diseases of the chest wall
__/__/__
7. Primary ciliary dyskinesia (immotile-cilia syndrome)
__/__/__
8. Pulmonary lymphangioleiomyomatosis
__/__/__
9. Disorders of ventilatory control
__/__/__
10. Hepatopulmonary syndrome
__/__/__
11. High altitude disease in adults
__/__/__
Pleural Disease
1. ATS guidelines: Management of malignant pleural effusions
__/__/__
2. Diagnostic evaluation of a pleural effusion
__/__/__
3. Tube thoracostomy
__/__/__
4 Choice of agents for pleurodesis
__/__/__
5. Pathogenesis and management of parapneumonic effusions and
empyema
6. The undiagnosed pleural effusion
__/__/__
__/__/__
7. Diagnosis and management of chylothorax and chyliform effusions
__/__/__
8. Causes and management of secondary spontaneous pneumothorax
__/__/__
36
9. Primary spontaneous pneumothorax
__/__/__
10. Diagnosis and management of trapped lung
__/__/__
11. Diagnostic thoracentesis
__/__/__
12. Imaging of pleural effusions
__/__/__
13. Mechanisms of pleural liquid accumulation in disease
__/__/__
14. Pleural effusion in AIDS
__/__/__
15. Pleural effusions following cardiac surgery
__/__/__
16. Pneumothorax in HIV-infected patients
__/__/__
17. Pneumothorax and air travel
__/__/__
18. Clinical presentation and staging of malignant mesothelioma
__/__/__
Pulmonary Function Testing/Physiology
1. Overview of pulmonary function testing
__/__/__
2. Diffusing capacity for carbon monoxide
__/__/__
3. Flow-volume loops
__/__/__
4. Exercise physiology
__/__/__
5. Physiologic changes following lung transplantation
__/__/__
6. Reference values for pulmonary function testing
__/__/__
7. Physiology and clinical use of heliox
__/__/__
Pulmonary Infections
1. Clinical microbiology review: Respiratory tract infections
__/__/__
2. ATS guidelines: Community-acquired pneumonia in adults
__/__/__
3. Community-acquired pneumonia: Risk stratification and the decision
to admit
__/__/__
4. Exacerbations of chronic bronchitis
__/__/__
5. Lung abscess
__/__/__
37
6. Non-resolving pneumonia
__/__/__
7. Approach to the HIV-infected patient with pulmonary symptoms
__/__/__
8. Pulmonary infections with endemic fungi in AIDS
__/__/__
9. Clinical presentation and diagnosis of Pneumocystic carinii infection in
HIV-infected patients
__/__/__
10. Treatment of Pneumocystis carinii infection in HIV-infected patients
__/__/__
11. Pneumocystis carinii pneumonia in non-HIV-infected patients
__/__/__
12. Aspiration pneumonia
__/__/__
13. Diagnosis of ventilator-associated pneumonia
__/__/__
14. Nosocomial pneumonia
__/__/__
15. Fibrosing mediastinitis
__/__/__
16. Diagnostic approach to the patient with community-acquired pneumonia
__/__/__
17. Treatment of community-acquired pneumonia
18. Pneumococcal pneumonia
__/__/__
__/__/__
19. Clinical manifestations and diagnosis of Legionella infection
__/__/__
20. Pneumococcal vaccination in adults
__/__/__
21. Use of fluoroquinolones in the treatment of respiratory tract infections
__/__/__
22. Prophylaxis against Pneumocystis carinii in HIV-infected patients
__/__/__
23. Cytomegalovirus infection as a cause of pulmonary disease in
HIV-infected patients
24. Pulmonary aspergillosis in HIV-infected patients
__/__/__
__/__/__
25. ATS guidelines: Hospital-acquired pneumonia in adults
__/__/__
26. Hantavirus pulmonary syndrome
__/__/__
38
PULMONARY
Pulmonary HTN
1. Pathophysiology and clinical aspects of primary pulmonary hypertension
__/__/__
2. Prognosis and treatment of primary pulmonary hypertension
__/__/__
3. Clinical manifestations and diagnosis of chronic thromboembolic
pulmonary hypertension
__/__/__
4. Clinical manifestations and diagnosis of secondary pulmonary
hypertension
__/__/__
5. Treatment of secondary pulmonary hypertension
__/__/__
6. Cor pulmonale
__/__/__
7. Pulmonary veno-occlusive disease
__/__/__
8. Portopulmonary hypertension
__/__/__
9. Use of inhaled nitric oxide in patients with pulmonary hypertension
__/__/__
Venous Insufficiency/Thromboembolism
1. ATS guidelines: The diagnostic approach to acute venous
thromboembolism
__/__/__
2. Treatment of acute pulmonary embolism
__/__/__
3. Treatment of deep vein thrombosis
__/__/__
4. Inferior vena caval filters
__/__/__
5. Low molecular weight heparin for venous thromboembolic disease
__/__/__
6. Prevention of venous thromboembolic disease
__/__/__
7. Clinical manifestations of and diagnostic strategies for acute pulmonary
embolism
8. Catheter-induced upper extremity venous thrombosis
__/__/__
__/__/__
39
9. Diagnosis of suspected deep vein thrombosis of the lower extremity
__/__/__
10. Overview of the causes of venous thrombosis
__/__/__
11. Thrombolytic therapy in venous thromboembolism
__/__/__
12. Massive pulmonary embolism
__/__/__
13. Venous thromboembolism is pregnancy
14. Hyperhomocysteinemia
__/__/__
__/__/__
Miscellaneous Embolic Disease
1. Air embolism
__/__/__
2. Fat embolism syndrome
__/__/__
3. Pulmonary tumor embolism
__/__/__
4. Fat embolism syndrome
__/__/__
5. Amniotic fluid embolism
__/__/__
Miscellaneous
1. Arteriovenous malformations of the pulmonary circulation:
Diagnosis and treatment
__/__/__
Sarcoidosis
1. ATS guidelines: Statement on sarcoidosis
__/__/__
2. Overview of sarcoidosis
__/__/__
3. Treatment of pulmonary sarcoidosis with corticosteroids
__/__/__
4. Treatment of pulmonary sarcoidosis with alternatives to corticosteroid
__/__/__
Sleep Medicine
1. Classification of sleep disorders
__/__/__
2. An overview of obstructive sleep apnea: Epidemiology,
pathophysiology, clinical presentation, and treatment
__/__/__
3. ATS guidelines: Indications and standards for cardiopulmonary
40
sleep studies
__/__/__
4. ATS guidelines: Indications and standards for use of nasal
continuous positive airway pressure (CPAP) in sleep apnea syndromes
__/__/__
5. Clinical manifestations and diagnosis of obesity hypoventilation
syndrome
__/__/__
6. Treatment of the obesity hypoventilation syndrome
__/__/__
7. Polysomnography in the diagnostic evaluation of sleep apnea
__/__/__
8. Quantifying sleepiness: Test of daytime somnolence
__/__/__
9. Clinical Presentation and diagnostic approach to sleep apnea
__/__/__
10. Legal responsibilities of physicians caring for automobile drivers with
sleep apnea
__/__/__
11. Evaluation of the snoring patient
__/__/__
Thoracic Imaging
1. Radiologic patterns of lobar atelectasis
__/__/__
2. Principles of conventional and helical CT scanning
__/__/__
3. Differential diagnosis and evaluation of multiple pulmonary nodules
__/__/__
4. Imaging of pleural plaques, thickening, and tumors
__/__/__
5. Imaging of Pneumothorax
__/__/__
6. Evaluation of diffuse lung disease by plain chest radiography
__/__/__
7. High resolution computed tomography of the lungs
__/__/__
8. Differential diagnosis and evaluation of the solitary pulmonary nodule
__/__/__
41
9. Evaluation of mediastinal masses
__/__/__
10. Magnetic resonance imaging of the thorax
__/__/__
Tuberculosis
1.
Clinical manifestations of pulmonary tuberculosis
__/__/__
2.
General principles of the treatment of tuberculosis
__/__/__
3. Treatment of tuberculosis in HIV-infected patients
__/__/__
4. ATS guidelines: Targeted tuberculin testing and treatment of latent
tuberculosis infection
__/__/__
5. ATS guidelines: Treatment of tuberculosis and tuberculosis infection in
adults and children Diagnosis and management of tuberculous pleural
effusions in non-HIV infected patients
__/__/__
6. Tuberculous pleural effusions in HIV-infected patients
__/__/__
7. Treatment of latent tuberculosis infection in HIV-infected patients
__/__/__
8. Tuberculosis in pregnancy
__/__/__
9. Diagnosis and treatment of drug-resistant tuberculosis
__/__/__
10. Interactive interpreter of the tuberculin skin test reaction (PPD 5 TU)
__/__/__
CRITICAL CARE MEDICINE
PROGRAM CONTENT FOR FELLOWSHIP TRAINING
I.
Specific Credentials
A. Provider and/or instructor status in Advanced Cardiac Life Support
(ACLS).
B. Provider and/or instructor status in Advanced Trauma Life Support
(ATLS)(optional)
42
C. Provider and/or instructor status in Pediatric Advanced Life Support
(PALS)(optional)
D. Provider and/or instructor status in Fundamental Critical Care Support
(FCCS)(optional)
II.
Procedural Skills
A. Airway Management
1. Maintenance of open airway in non-intubated patients; by mask
ventilation, LMA ventilation
2. Tracheal Intubation (oral via laryngoscope and bronchoscope)
3. Percutaneous Dilational Tracheostomy with bronchoscope guidance
(contingent upon available faculty expertise)
4. Cricothyrotomy (optional)
B. Ventilation
1. Oxygen therapy
2. Respiratory monitoring (noninvasive and invasive); blood gas analysis
3. Use of bronchodilators, humidifiers and intermittent positive pressure
breathing therapy
4. Suction and chest physiotherapy technique
5. Ventilation by bag and mask and laryngeal mask airway
6.
Interpretation of chest radiographs and chest CT scans in critically ill
patients
7. Chest tube insertion and management
8. Prevention, diagnosis and management of pulmonary
thromboembolism
9. Mechanical ventilation:
a. Operation of mechanical ventilators:
1. Assist control ventilation (AC)
2. Synchronized Intermittent mandatory ventilation (SMIV)
3. Pressure support ventilation (PS)
4. Application of continuous positive airway pressure (CPAP)
5. Application of positive end-expiratory pressure (PEEP)
6. Recognition and Management of Auto-PEEP
43
7. Other modes of mechanical ventilation such as pressure
regulated volume controlled (PRVC), pressure controlled (PC)
b.
Monitoring airway pressures
c.
Measurement of endotracheal tube cuff pressures
d.
Management of barotrauma/volutrauma
e.
Fiberoptic bronchoscopy in intubated patients
f.
Weaning techniques and RT driven weaning protocols
C. Cardiovascular System
1. Cardiopulmonary resuscitation
2. Arterial puncture
3. Insertion of monitoring lines:
a. Arterial
b. Central venous
c. Pulmonary artery catheters
4. Management of arterial and venous air embolism
5. Determination and interpretation of cardiac output, vascular
resistance, oxygen content, oxygen delivery, oxygen consumption,
shunt fraction, alveolar-arterial oxygen gradient and other derived
parameters
6. Infusion of vasoactive drugs
7. Interpretation of electrocardiograms
8. Insertion of transvenous pacemakers
9. Temporary cardiac pacing (transcutaneous and transvenous)
10. Cardioversion
11. Pericardiocentesis
12. Application and regulation of intra-aortic assist devices (optional)
13. Echocardiography (optional)
D. Central Nervous System
1. Lumbar puncture
2. Use of sedatives, analgesics and muscle relaxants
3. Intracranial pressure monitoring
4. Electroencephalography (optional)
44
E. Renal
1. Insertion of hemodialysis catheters (optional)
2. Management of continuous arteriovenous and venovenous hemofiltration,
and hemodialysis (optional)
3. Management of peritoneal dialysis (optional)
F. Gastrointestinal
1. Prevention and management of upper gastrointestinal bleeding
2. Gastrointestinal endoscopy (optional)
3. Abdominal ultrasonography (optional)
G. Infection
1.
ICU sterility techniques and precautions
2. Sampling and interpretation of body fluids including
blood, sputum, urine, pleural fluid, peritoneal fluid and CSF
3.
Interpretation of culture sensitivities
4.
Monitoring serum antibiotic levels
5.
Empiric antibiotic selection
H. Hematology
1. Utilization of blood component therapy
2. Interpretation of coagulation studies and management of
coagulation disorders
3. Massive transfusions
4. Autotransfusion (optional)
I. Nutrition and Metabolism
1. Enteral nutrition
2. Parenteral nutrition
3 Monitoring metabolism and nutrition
J. Trauma
1. Peritoneal lavage (optional)
K. Bioengineering
45
1. Trouble shooting equipment
2. Use of amplifiers and recorders
3. Calibration of transducers
III. Cognitive Skills
A. Pulmonary Disorders (Physiology, Pathology, Pathophysiology and
Therapy):
1. Acute respiratory failure (hypoxemic vs hypercapnic)
2. Adult respiratory distress syndrome (ARDS)
3. Status asthmaticus
4. Acute exacerbation of chronic obstructive pulmonary disease
5. Non-pulmonary causes of respiratory failure
6. Pneumonia and other bronchopulmonary infections
7. Upper airway obstruction
8. Inhalation injuries (smoke, toxic gas and fumes)
9. Aspiration and chemical pneumonitis
10. Chest trauma including flail chest
11. Pneumothorax
12. Drowning
13. Pulmonary thromboembolism
14. Massive hemoptysis
15. Sleep apnea (central and obstructive)
16. Pulmonary function tests and arterial blood gas interpretation
17. Oxygen therapy; oxygen toxicity
18. Respiratory complications of critical illness
19. Airway maintenance
20. Mechanical ventilation
21. Extracorporeal membrane oxygenation (optional)
B. Cardiovascular Disorders (Physiology, Pathology,
Pathophysiology and Therapy)
46
1. Shock and multiple organ failure
a. Cardiogenic
b. Septic/Distributive
c. Hypovolemic
2. Myocardial infarction and unstable angina
a. Thrombolytic therapy
b. Complications of angioplasty (optional)
3.
Cardiac arrhythmias and conduction disturbances
4.
Pulmonary edema (cardiogenic)
5.
Cardiac tamponade and other acute pericardial Diseases
6.
Hypertensive crisis/emergency
7.
Acute aortic dissection
8.
Acute valvular heart disorders
9.
Acute complications of myocarditis and cardiomyopathies
10.
Vasoactive and inotropic therapy for heart failure
11.
Measurement and interpretation of hemodynamic parameters
12.
Hemodynamic effects of positive pressure ventilation
13. Perioperative management of post operative and cardiac
surgical patients (optional)
C. Central Nervous System Disorders (Physiology, Pathology,
Pathophysiology and Therapy)
1.
Coma
a. Vascular/anoxic/ischemic
b. Metabolic/Toxic/Drug over dose
c. Infectious
d. Traumatic
e. Related to mass lesions
2.
Brain death criteria
3.
Persistent vegetative states
4.
Seizures including status epilepticus
5. Myasthenia gravis ALS, neuro-muscular weakness
6.
Sedation, analgesia and neuromuscular blockade
47
7.
Perioperative management of neurologic surgical patients
8.
Psychiatric emergencies
D. Renal Disorders (Physiology, Pathology, Pathophysiology
and Therapy)
1. Fluid balance and electrolytes management
2. Renal failure (acute and chronic)
3. Electrolyte, osmolality and acid-base derangement and their
management
4. Principles of hemodialysis, peritoneal dialysis, ultrafiltration,
continuous arteriovenous hemofiltration and continuous veno-venous
hemofiltration
5. Interpretation of urine electrolytes and FENa
6. Drug dosing in renal failure
7. Obstructive uropathy and acute urinary retention
8. Urinary tract bleeding
E. Gastrointestinal Disorders (Physiology, Pathology, Pathophysiology
and Therapy)
1. Hepatic failure
2. Drug dosing in hepatic failure
3. Gastrointestinal hemorrhage
a. upper GI bleeding
b. lower GI bleeding
4. Stress ulcer prophylaxis
5. Acute pancreatitis
6. Toxic megacolon
7. Acute perforation/s of the gastrointestinal tract including esophageal
rupture
8. Acute inflammatory diseases of the intestine and peritonitis
48
9. Acute vascular disorders of the intestine including mesenteric
ischemia or infarction
F. Infectious Diseases (Physiology, Pathology,
Pathophysiology and Therapy)
1.
Nosocomial infection in the intensive care unit
2.
Antimicrobial, antifungal and antiviral therapy
3.
Infection control
4. Infectious risks to healthcare workers
5. Critically ill immunosuppressed host
6.
Specific infections with critical care implications:
a.
Sepsis
b.
Tetanus
c.
Anaerobic infections
d.
Acquired immunodeficiency syndrome
e.
Toxic shock syndrome
f.
Infective endocarditis
g.
Ventilator acquired pneumonia
h.
Catheter associated infections (blood and urine)
G. Hematologic Disorders (Physiology, Pathology, Pathophysiology and
Therapy
1.
Acute defects in hemostasis
a. Thrombocytopenia
b. Disseminated intravascular coagulation
2.
Anticoagulation and fibrinolytic therapy
3.
Acute hemolytic disorders
4.
Acute syndromes associated with neoplastic diseases and
antineoplastic therapy
5. Acute disorders of immunosuppressed patients
6. Sickle cell crisis
7.
Blood component therapy
49
8.
Plasma pheresis (optional)
H. Endocrine Disorders (Physiology, Pathology, Pathophysiology and
Therapy)
1.
Disorders of thyroid function
a. Myxedema coma
b. Thyroid storm
c. Sick euthyroid syndrome
2.
Adrenal crisis
3.
Syndrome of inappropriate antidiuretic hormone secretion and
diabetes insipidus
4.
Diabetes mellitus:
a. Diabetic ketoacidosis
b. Hyperosmolar non-acidotic nonketotic coma
c. Hypoglycemia
5.
Pheochromocytoma
6.
Disorders of calcium and magnesium
I. Nutrition
1.
Enteral feeding
2.
Parenteral nutrition
3.
Monitoring nutritional status
J. Physical and Toxic Injuries
1.
Initial management of multisystem trauma
2.
Central nervous system trauma
3.
Skeletal trauma
4.
Chest trauma (blunt and penetrating)
5.
Abdominal trauma
6.
Crush injuries
7.
Burns
8.
Acute poisoning
50
9.
Drowning
10.
Hypothermia
11.
Hyperthermia:
a. Heatstroke
b. Malignant hyperthermia
c. Neuroleptic malignant syndrome
12.
Anaphylaxis
K. Immunology and Transplantation
1. Principles of organ donation (ARORA)
2. Indications and postoperative care of organ transplantation
3. Immunosuppression
L. Care of the Pregnant Patient
1. Toxemia of pregnancy
2. Peripartum cardiomyopathy
3. Perioperative management of the critically ill pregnant patient
4. Drug selection in pregnancy
M. Pharmacokinetics and Pharmacodynamics
1.
Drug metabolism and excretion in critical illness
2.
Drug monitoring and dose in critical illness
N. Bioengineering and Monitoring
1. Invasive hemodynamic monitoring:
a. Principle of strain gauge transducers
b. Signal conditioners, calibration, gain, and adjustment
c. Display techniques
2. Noninvasive hemodynamic monitoring
3. Brain monitoring:
a. Intracranial pressure
51
b. Cerebral blood flow (optional)
c. Electroencephalography (optional)
4. Respiratory monitoring
5. Use of computers in critical care units
6. Prognostic scoring systems such as APACHE/MPM/SADS/PSI
0.
Ethical and Legal Aspects of Critical Care Medicine
1. Death and dying
2. Foregoing life-sustaining treatment and "do not resuscitate"
orders
3. Standards of treatment for the handicapped and mentally
retarded
4. Rights of patients; the right to refuse treatment
5. Living wills, advance directives and durable power of attorney
6. Physiologic and social effects of life-threatening illness on patients
and families
P. Administrative and Management Principles and Techniques
1. Organization and staffing of critical care units
2. Standards for special care units (Joint Commission on Accreditation of
Healthcare Organizations)
3. Medical record keeping in the intensive care unit
4. Quality improvement: principles, and practices
5. Principles of triage and resource allocation
6. Design of special care units
7. Medical economics: hospital financial reimbursement, critical care
billing
Q. Research in Critical Care Medicine
1. Biostatistics
2. Grant design and preparation
3. Interpretation of research data
52
IV. References
1. American College of Critical Care Medicine of the Society of Critical Care
Medicine. Guidelines for advanced training for physicians in critical care. Crit
Care Med 1997; 25:1601-1607
2. Guidelines Committee, Society of Critical Care Medicine. Guidelines for program
content for fellowship training in critical care medicine. Crit Care Med 1992;
20:875-882
3. Guidelines Committee, Society of Critical Care Medicine. Guidelines for the
definition of an intensivist and the practice of critical care medicine. Crit Care
Med 1992; 20:540-542
4. European Society of Intensive Care Medicine, European Society of Pediatric
Intensive Care. Guidelines for a training program in intensive care medicine.
Intensive Care Med 1996; 22:166-172
5. European Society of Intensive Care Medicine. Guidelines for training in
intensive care medicine. Intensive Care Med 1994; 20:80-81
6. Horst HM, Brilli RJ, Soifer BE, Rivers EP, Vukmir RB, Maxwell DL, Mason B,
Haupt MT. Physician certification and program accreditation in critical care
medicine: The experience of program directors. New Horizons 1998; 6:260268
7. Weil MH. Physician education in critical care medicine. New Horizons 1998;
6:235-238
8. Campbell ML. Teaching medical ethics in critical care. New Horizons 1998;
6:289-292
9. Powner DJ, Rieker 3P. Teaching administrative skills in critical care medicine.
New Horizons 1998; 6:282-288
10. Kvetan V. Training of critical care physician managers. New
Horizons 1998;
6:269-273
11. Pinsky MR. Research training in critical care medicine. New Horizons;
1998:6:293-299
CRITICAL CARE MEDICINE
53
DUTIES AND RESPONSIBILITIES OF FELLOWS
OVERVIEW AND GOALS
Critical care medicine involves the diagnosis and treatment of clinical conditions
representing the extremes of human diseases. The educational objectives of
training in critical care medicine for the sub-specialist include (1) assessment and
triage of critically ill patients, (2) diagnosis and management of critically ill
patients, (3) selection, proper performance and interpretation of monitoring
techniques used in the care of critically ill patients, and (4) utilization of
consultants in the care of critically ill patients. In addition to a comprehensive
knowledge of internal medicine critical care training requires knowledge in
neurology, surgery and anesthesiology. The care of critically ill patients often
raises ethical issues, and critical care medicine trainee should develop
competence in areas of advanced directives, patient and family counseling, and
end-of-life decisions. Critical care trainees should also acquire the necessary
skills to participate in the administration of critical care units, to educate critical
care personnel, patients and their families and the public, as well as to conduct
research in the field of critical care medicine. In summary, the goal of training in
critical care medicine is the development of a competent critical care clinician,
educator, scientist and administrator.
EDUCATIONAL CONTENT, INCLUDING THE MIX OF DISEASES, PATIENT
CHARACTERISTICS, TYPES OF CLINICAL ENCOUNTERS, PROCEDURES
AND SERVICES
The Division of Pulmonary/CCM operates the MICU at the University of Arkansas
for Medical Sciences Hospital and the Central Arkansas Veterans Healthcare
System. Both institutions serve as referral centers for the state of Arkansas. The
Veterans' Medical Center has one of the nations largest veterans' Internal Medicine
services in the country and offers a solid exposure to a wide variety of medical
54
conditions. The combined clinical populations of these two institutions provide a
diverse clinical experience including acute respiratory failure, shock, sepsis,
gastrointestinal hemorrhage, acute renal failure, fluid electrolyte and acid-base
derangements, hepatic failure, coma, acute intoxications, etc.…The UAMS
University Hospital has an active Medical Oncology program and a large peripheral
blood stem cell transplant program focused on Multiple Myeloma. These services
provide MICU fellows significant exposure to respiratory failure due to opportunistic
infections, treatment related lung injury (radiation pneumonitis, chemotherapy lung
injury, or septic shock, tumor lysis syndrome, etc.…The UAMS University Hospital
has active surgical (general, neurosurgery and cardiovascular) and obstetric (highrisk pregnancies and deliveries) services. These services routinely consult the
Pulmonary/CCM team. The MICU services at both institutions offer ample
opportunities for performing procedures utilized in Critical Care Medicine.
FELLOW RESPONSIBILITIES
The critical care fellow will have two categorical critical care rotations: UAMS
Medical Center and Central Arkansas Veterans Healthcare System Medical Center.
UAMS MEDICAL CENTER AND CAVHS MEDICAL CENTER
1. UAMS
MEDICAL
CENTER
UNIVERSITY
HOSPITAL
CATEGORICAL
CRITICAL CARE ROTATION (UNIVERSITY MICU)
The MICU fellow is an integral member of the MICU team. The fellow rounds daily
with the MICU team and is available to guide the MICU team’s management of
critically ill patients. The MICU team is comprised of an Internal Medicine resident,
55
two interns, a Pulmonary Critical Care Medicine faculty member and fellow, and
representatives from hospital pharmacy and respiratory therapy. The fellow is
directly responsible to the MICU attending, who is a faculty member of the
Pulmonary/Critical Care Medicine Division. Fellows are notified regarding all MICU
admissions and transfers and they are, in turn, responsible for discussing the case
with the MICU attending. Fellows write an initial "MICU FELLOW NOTE", which
summarizes the history and physical and laboratory findings and outlines a
diagnostic and/or treatment plan. Fellows are present for all pulmonary artery
catheter placements and assist the MICU team with other procedures such as
endotracheal intubation, central venous catheter insertion, thoracentesis, and
ventilator management. The MICU fellow participates in sign-out rounds with the
MICU team each evening. The fellow conducts informal lectures on MICUrelated topics for the MICU housestaff and medical students rotating through
the MICU. In summary, the fellow provides on-going clinical guidance, education,
procedural assistance and administrative management for the MICU service.
2. VETERANS' MEDICAL CENTER
CATEGORICAL CRITICAL CARE ROTATION (VA – MICU)
The VA MICU fellow is a key member of the VA MICU team. The MICU fellow
rounds daily, with the MICU team, and oversees the care of the MICU patients.
Fellows are notified of all admissions to the MICU and they, in turn, are responsible
for relaying this information to the MICU attending, who is a Pulmonary/Critical Care
Medicine Division faculty member. For every admission, fellows enter an initial
"MICU FELLOW NOTE". Fellows are present for all pulmonary artery catheter
placements and assist with other ICU procedures as deemed necessary. The fellow
conducts informal lectures on MICU-related topics for the MICU housestaff
and medical students rotating through the MICU. The MICU fellow conducts
daily sign out rounds with the MICU housestaff.
The MICU fellow serves as a
consultant to the Coronary Care Unit for pulmonary problems and critical care
procedures. During one VA MICU rotation month, the fellow rounds in the VAMC
Coronary Care Unit to strengthen his/her exposure to cardiovascular critical care
VETERANS' MEDICAL CENTER MICU TEAM LEADER (3RD YEAR FELLOW)
56
During the third year of training, the fellow serves as the MICU team leader for one
month in the VA MICU. The fellow rounds independently with the MICU team. The
Pulmonary/Critical Care Medicine Division faculty assigned to the VA Pulmonary
Consultation service supervises the fellow and rounds daily with the fellow. In this
capacity, the fellow rounds daily with the MICU team and functions as the MICU
attending. The fellow writes admission notes for all MICU admissions and transfers
from the MICU service to the hospital floor. A first or second year fellow may be
assigned to the VA MICU service for regular fellow responsibilities during this
month.
METHODS USED TO EVALUATE THE FELLOW, ATTENDING AND PROGRAM
1. The Intensive Care Unit Attending completes a formal evaluation (New
Innovation; see attached form) of the fellows at the end of each MICU rotation.
Verbal feedback from the MICU Attending to individual fellows takes place
during rotations.
2. At the end of each rotation, the MICU fellow formally evaluates the MICU
attending; (New Innovations see attached) strict confidentiality is maintained.
The fellow’s evaluations of the MICU attending are forwarded to the Division
Director, and are reviewed by the faculty members during their annual review.
3. The MICU rotations are discussed during the monthly fellow's meetings and
they are evaluated in the semi-annual fellow’s evaluations.
4. The Fellowship Education Committee reviews program content on an annual
basis.
5. The program director supplies feedback and details of the rotation’s strengths
and limitations to the Pulmonary/CCM faculty, as needed, at the monthly faculty
meeting.
6. In-service Pulmonary and Critical Care Medicine exams are administered each
year to incoming, 1st, 2nd and 3rd year fellows.
During the MICU rotations, fellows are evaluated on their ability to appropriately
perform the 6 clinical competencies listed below.
57
PATIENT CARE: The fellow provides compassionate care that is effective for the
promotion of health, prevention, treatment, and at the end of life.
MEDICAL JUDGMENT:
The fellow demonstrates knowledge of biomedical,
clinical and social sciences and applies that knowledge effectively to patient care.
PRACTICE BASED LEARNING AND IMPROVEMENT:
The
fellow
uses
evidence and methods to investigate, evaluate and improve his/her patient care
practices.
COMMUNICATION AND INTERPERSONAL SKILLS:
The fellow maintains
these skills and maintains professional and therapeutic relationships with
patients and the Health Care Team.
PROFESSIONALISM:
The fellow demonstrates behavior that reflects an
ongoing commitment to continuous professional development, ethical practice,
sensitivity to diversity and responsible attitudes.
SYSTEM BASED PRACTICE: The fellow demonstrates both an understanding of
the context and systems in which health care is provided and applies this
knowledge to improve and optimize health care.
PROCEDURAL SKILLS:
Successful
mastery
of
therapeutic procedures within the subspecialty.
perform
the
necessary
manual
skills,
the
diagnostic
and/or
This includes the ability to
understand
the
indications,
contraindications, complications for a procedure, and the ability to interpret the
results.
1. Flexible bronchoscopy (overall)
a. BAL
b. TBBx
c. TBNA
2. Transthoracic needle aspiration
58
3. Thoracentesis
4. Close tube thoracostomy
5. Closed pleural biopsy (optional)
6. Right heart catheterization
7. Central venous catheterization
8. Arterial catheterization
9. Hemodynamic monitoring
10. Pulmonary function testing
11. Cardiopulmonary resuscitation
12. Airway establishment and maintenance
13. Tracheal Intubation
a. Laryngoscope
b. Flexible bronchoscope
14. Mechanical ventilatory support
15. Noninvasive ventilation
16. Respiratory care
17. Interpretation of studies
PRINCIPAL TEACHING METHODS USED DURING THIS ROTATION
[X] Attending teaching rounds
[X] Patient management discussions
[X] Conferences specific to rotation
[X] Individual instruction of procedures
[X] Computer-based learning
[X] Interdisciplinary rounds
[X] Small group discussions
[X] Bedside clinical rounds
[X] Review of diagnostic studies
[X] Ethics rounds
59
PROGRESSIVE EDUCATIONAL OPPORTUNITIES
The fellows are assigned to the MICU rotations for 1 to 2 month blocks during all
three years of their fellowship. Initially, the fellow is supervised closely in patient
evaluations, therapeutic selections, clinical decision making and procedures by the
faculty attending. The fellows are allowed progressively more autonomy based on
their performance and competence as they progress through the fellowship.
During the weekend the MICU fellow may round independently, with the MICU
team and then round one-on-one with the faculty member on call for the weekend.
PRINCIPAL ANCILLARY EDUCATIONAL MATERIALS USED
[X] Reading from recommended texts
[X] Radiological studies
[X] Handouts on relevant topics
[X] Computer-based learning
[X] Board review questions
[X] Pathologic materials
[X] Other noninvasive studies
[X] Articles from the core literature
[X] Case studies
STRENGTHS AND LIMITATIONS SPECIFIC TO THE RESOURCES OF THE
SPONSORING INSTITUTION
The MICUs of the University of Arkansas for Medical Sciences University Hospital
and the Central Arkansas Veterans Healthcare System are state of the art facilities
and have the complete complement of support services.
CRITICAL CARE MEDICINE
SELF-DIRECTED LEARNING CURRICULUM (UP-TO-DATE)
60
Name__________________________ Date completed_______________
I. Pulmonary Disorders:
1. Acute respiratory distress syndrome:
a. Definition, diagnosis and etiology
__/__/__
b. Interpretation of arterial oxygen tension
__/__/__
c. Mechanical ventilation in acute respiratory distress syndrome
__/__/__
d. Novel therapies for the acute respiratory distress syndrome
__/__/__
2. Pathogenesis and management of status asthmaticus
__/__/__
3. Respiratory considerations in my asthenia gravis
__/__/__
4. Respiratory failure from peripheral neuromuscular disease
__/__/__
5. Smoke inhalation
__/__/__
6. Pulmonary embolism:
a. Diagnostic strategies for acute pulmonary embolism
__/__/__
b. Inferior vena caval filters
c. Air embolism
d. Fat embolism syndrome
_/__/__
__/__/__
__/__/__
7. Mechanical ventilation:
a. Troubleshooting problems with noninvasive positive pressure ventilation
__/__/__
b. Endotracheal tube management
__/__/__
c. Conventional mechanical ventilation
__/__/__
d. Alternate modes of mechanical ventilation
__/__/__
e. Positive end-expiratory pressure (PEEP)
__/__/__
61
f. Physiologic and pathophysiologic consequences of PPV
__/__/__
g. Permissive hypercapnic ventilation
__/__/__
h. Mechanical ventilation in acute respiratory failure complicating COPD
__/__/__
i. Liquid ventilation
j.
__/__/__
Management of BP fistula in patients on mechanical ventilation
__/__/__
k. Methods of discontinuing mechanical ventilation
__/__/__
l. Objective predictors of weaning
__/__/__
m. Management of the difficult-to-wean patient
__/__/__
n. Oxygen toxicity
__/__/__
o. Pulse oximetry
__/__/__
p. Interpretation of arterial oxygen tension
II.
__/__/__
Cardiovascular Disorders;
1. Controversies in cardiopulmonary resuscitation
__/__/__
2. Shock:
a. General evaluation and differential diagnosis of shock
__/__/__
b. Clinical manifestations and diagnosis of cardiogenic shock
__/__/__
c. Treatment of cardiogenic shock
__/__/__
d. Fluid replacement in volume depletion
__/__/__
e. Treatment of severe hypovolemia or hypovolemic shock
__/__/__
f. Physiology and principles of the use of vasopressors and inotropic
__/__/__
g. Management of septic shock
__/__/__
3. Myocardial infarction and acute ischemic syndromes:
a. Overview of the management of acute MI
__/__/__
b. Acute therapy and outcome of sudden cardiac death
__/__/__
62
c. Blood tests in the diagnosis of acute myocardial infarction
__/__/__
d. Electrocardiogram in myocardial ischemia and infarction
__/__/__
e. EK.G diagnosis of MI in the presence of bundle branch block
__/__/__
f. Mechanical complications of acute MI
__/__/__
g. Right ventricular myocardial infarction
__/__/__
h. Overview of the management of unstable angina
__/__/__
i. Anti ischemic agents in the management of unstable angina
__/__/__
4. Cardiac arrhythmias and conduction disturbances:
a. Differential diagnosis of basic EK.G abnormalities
b. Atrial tachycardias
__/__/__
__/__/__
c. Overview of the presentation and management of atrial fibrillation
__/__/__
d. Treatment of atrial flutter: Overview
__/__/__
e. Approach to narrow QRS complex tachycardias
__/__/__
f. Treatment of nonsustained ventricular tachycardia
__/__/__
g. Sinoatrial nodal pause; arrest; and exit block
__/__/__
h. Second degree atrioventricular block: Mobitz type 1
__/__/__
i. Second degree atrioventricular block: Mobitz type 2
__/__/__
j.
Third degree (complete) atrioventricular block
__/__/__
k. EKG interpretation of LBBB
__/__/__
1. EKG interpretation of RBBB
__/__/__
m. Basic approach to delayed intraventricular conduction
__/__/__
n. Conduction abnormalities after myocardial infarction
__/__/__
o. Treatment of the sick sinus syndrome
__/__/__
63
p. Modes of cardiac pacing: Nomenclature and selection
__/__/__
5. Pulmonary edema:
a. Etiology and treatment of cardiogenic pulmonary edema
__/__/__
b. Overview of the therapeutic approach to CHF
__/__/__
c. Pharmacologic therapy of symptomatic CHF
__/__/__
d. Etiology and treatment of noncardiogenic pulmonary edema
e. Neurogenic pulmonary edema
__/__/__
__/__/__
6. Hypertensive crisis:
a. Hypertensive emergencies: Malignant HTN and HTN encephalopathy
__/__/__
b. Drug treatment of hypertensive emergencies
__/__/__
c. Treatment of specific hypertensive emergencies
__/__/__
d. Severe asymptomatic HTN (hypertensive urgencies)
__/__/__
7. Management of aortic dissection
__/__/__
8. Pulmonary artery catheter:
a. Swan-Ganz catheterization: Indications and complications
__/__/__
b. Insertion of Swan-Ganz catheters
c. Swan-Ganz catheterization: Interpretation of tracings
_/__/__
__/__/__
9. Intra-aortic balloon counterpulsation
III.
Central Nervous System Disorders:
1. Neuromuscular disorders of critical illness
__/__/__
2. Guillain-Barré syndrome
__/__/__
3. Use of sedative medications in critically ill patients
__/__/__
4. Use of neuromuscular blocking medications in critically ill patients
__/__/__
5. Pain control in the intensive care
__/__/__
64
IV.
Renal Disorders:
1. Renal regulation of fluid balance and electrolytes:
a. Creatinine clearance calculator
__/__/__
d. Fractional excretion of sodium in acute renal failure
__/__/__
e. Osmolal gap
f. Urine sodium versus urine chloride
g. Renal actions of dopamine
__/__/__
__/__/__
__/__/__
2. Renal failure:
a. Diagnosis of acute tubular necrosis and prerenal disease
__/__/__
b. Nonoliguric versus oliguric acute tubular necrosis
__/__/__
c. Duration and possible therapy of acute tubular necrosis
__/__/__
d. Radio contrast media-induced acute renal failure (ARF)
__/__/__
e. Dialysis in ARF: Indications and dialysis prescription
__/__/__
f. Dialysis in ARF: metabolic and hemodynamic considerations
__/__/__
g. Acute hemodialysis vascular access
__/__/__
h. Hemodynamic instability during hemodialysis: Overview
__/__/__
i. Red urine: Hematuria; hemoglobinuria; myoglobinuria
__/__/__
3. Acid-base abnormalities:
a. Acidosis:
1. Simple and mixed acid-base disorders
__/__/__
2. The anion gap/HC03 in metabolic acidosis
__/__/__
3. Anion gap in conditions other than metabolic acidosis
__/__/__
4. Anion gap in the differential diagnosis of metabolic acidosis
__/__/__
5. Urine anion and osmolal gaps in metabolic acidosis
__/__/__
6. Arterial and mixed venous blood gases in lactic acidosis
__/__/__
7. Alcoholic and fasting ketoacidosis
__/__/__
8. Treatment of metabolic acidosis
__/__/__
65
9. Treatment of metabolic acidosis in chronic renal failure
__/__/__
10. Bicarbonate therapy in ketoacidosis
__/__/__
11. Bicarbonate therapy in lactic acidosis
__/__/__
b. Alkalosis:
1. Pathogenesis of metabolic alkalosis
__/__/__
2. Urine electrolytes in diagnosis of metabolic alkalosis
__/__/__
3. Treatment of metabolic alkalosis
__/__/__
4. Electrolyte Abnormalities:
a. Hypernatremia:
1. Symptoms of hyponatremia and hypernatremia
__/__/__
2. Causes of hypernatremia
__/__/__
3. Diagnosis of hypernatremia
__/__/__
4. Treatment of hypernatremia
__/__/__
b. Hyponatremia:
1. Causes of hyponatremia
__/__/__
2. Hyponatremia in cirrhosis
__/__/__
3. Diagnosis of hyponatremia
__/__/__
4. Treatment of hyponatremia: Overview
__/__/__
5. Treatment of hyponatremia: Risk of osmotic demyelination
__/__/__
6. Treatment of hyponatremia: Saline or water restriction
__/__/__
7. Treatment of hyponatremia: SIADH and reset osmostat
__/__/__
8. Treatment of hyponatremia: Sodium deficit and rate of correction:
__/__/__
c. Hyperkalemia:
1. Causes of hyperkalemia
2. Treatment of hyperkalemia
__/__/__
__/__/__
d. Hypokalemia:
1. Causes of hypokalemia
__/__/__
2. Diagnosis of hypokalemia
__/__/__
3. Treatment of hypokalemia
__/__/__
e. Hypermagnesemia:
1. Symptoms of hypermagnesemia
2. Causes and treatment of hypermagnesemia
__/__/__
__/__/__
66
f. Hypomagnesemia:
1. Causes of hypomagnesemia
__/__/__
2. Signs and symptoms of magnesium depletion
__/__/__
3. Diagnosis and treatment of hypomagnesemia
__/__/__
g. Hyperphosphatemia:
1. Causes and treatment of hyperphosphatemia
__/__/__
h. Hypophosphatemia:
1. Causes of hypophosphatemia
__/__/__
2. Signs and symptoms of hypophosphatemia
__/__/__
3. Diagnosis and treatment of hypophosphatemia
__/__/__
i. Hypercalcemia:
j.
1. Etiology of hypercalcemia
__/__/__
2. Hypercalcemia of malignancy
__/__/__
3. Diagnostic approach to hypercalcemia
__/__/__
4. Treatment of hypercalcemia
__/__/__
Hypocalcemia:
1. Diagnostic approach to hypocalcemia
__/__/__
2. Relation between total and ionized plasma calcium concentration
__/__/__
3. Treatment of hypocalcemia
V.
__/__/__
Gastrointestinal Disorders:
1. Stress ulcer prophylaxis in the intensive care unit
__/__/__
2. Major causes of upper gastrointestinal bleeding
__/__/__
3. Uncommon causes of upper gastrointestinal bleeding
__/__/__
4. Treatment of bleeding peptic ulcers
__/__/__
5. Acute pancreatitis:
a. Etiology of acute pancreatitis
__/__/__
b. Pathogenesis of acute pancreatitis
__/__/__
c. Predicting the severity and treating acute pancreatitis
__/__/__
6. Diagnosis and treatment of hepatorenal syndrome
VI.
__/__/__
Infectious Diseases:
67
1. Nosocomial infection in the intensive care unit:
a. CVL-related infections: types of devices and definitions
__/__/__
b. Diagnosis and management of CVL-related infections
__/__/__
c. Diagnosis and epidemiology of nosocomial primary
bloodstream infections
__/__/__
d. Nosocomial pneumonia
__/__/__
e. Diagnosis of ventilator-associated pneumonia
__/__/__
2. Specific infections with critical care implications:
a. Sepsis and the SIRS: Definitions and prognosis
__/__/__
b. Pathophysiology of sepsis
__/__/__
c. Streptococcal toxic shock syndrome
__/__/__
d. Infective
endocarditis:
case
definitions
and
criteria
for
diagnosis__/__/__
VII.
Hematologic Disorders:
1. Use of blood products in the intensive care unit
__/__/__
2. Chemical and physical complications of blood transfusion
__/__/__
3. Immunologic blood transfusion reactions
__/__/__
4. Transfusion-related acute lung injury
__/__/__
5. Prescription and technique of therapeutic plasma exchange
__/__/__
6. Complications of therapeutic plasma exchange
__/__/__
7. Intensive care for oncology patients: Short-term prognosis
__/__/__
8. Tumor-lysis syndrome
__/__/__
9. Causes of HUS and TTP
__/__/__
10. Treatment of HUS and TTP
__/__/__
VIII. Endocrine Disorders:
1. Pathogenesis of DKA and nonketotic hyperglycemia
__/__/__
2. Diagnosis and treatment of DKA and nonketotic hyperglycemia __/__/__
68
3. Diagnosis of adrenal insufficiency
__/__/__
4. Hyponatremia and hyperkalemia in adrenal insufficiency
__/__/__
5. Evaluation of the response to ACTH in adrenal insufficiency
__/__/__
6. Treatment of adrenal insufficiency
__/__/__
7. Diagnosis of polyuria and diabetes insipidus
__/__/__
8. Causes of central diabetes insipidus
__/__/__
9. Treatment of central diabetes insipidus
__/__/__
10. Diagnosis and treatment of pheochromocytoma
__/__/__
11. Laboratory assessment of thyroid function
__/__/__
12. Thyroid function in non-thyroidal illness
__/__/__
13. Treatment of thyroid storm
__/__/__
IX. Nutrition:
1. Fundamentals of nutritional support in the critically ill
__/__/__
2. Assessment of nutrition in the critically ill
__/__/__
X. Physical and Toxic Injuries
1. Intensive care unit management of the trauma patient
__/__/__
2. Acute poisoning:
a. General approach to drug intoxications
__/__/__
b. Decontamination of poisoned patients
__/__/__
c. Enhanced elimination of poisons
__/__/__
d. Isopropyl alcohol intoxication
__/__/__
e. Treatment of methanol and ethylene glycol intoxication
__/__/__
f. Management of acetaminophen (paracetamol) intoxication
__/__/__
g. Management of aspirin intoxication
__/__/__
69
h. Management of digitalis intoxication
__/__/__
i. Basic approach to arrhythmias due to digitalis toxicity
__/__/__
j.
__/__/__
Management of lithium intoxication
k. Management of theophylline intoxication
__/__/__
l. Management of tricyclic antidepressant intoxication
3. Accidental hypothermia
__/__/__
__/__/__
4. Severe hyperthermia:
a. Heatstroke
__/__/__
b. Neuroleptic malignant syndrome
__/__/__
c. Malignant hyperthermia
__/__/__
5. Anaphylaxis
__/__/__
XI. Care of the Pregnant Patient:
1. Pharmacologic management of heart failure in pregnancy
__/__/__
XII. Pharmacokinetics and Pharmacodynamics:
1. Clinical use of amiodarone
__/__/__
2. Major side effects of amiodarone
__/__/__
3. Clinical use of lidocaine
__/__/__
4. Major side effects of lidocaine
__/__/__
5. Procainamide: Pharmacokinetics; dose; and route of administration __/__/__
6. Major side effects of procainamide
__/__/__
7. Quinidine: Pharmacokinetics; dose; and route of administration
__/__/__
8. Major side effects of quinidine
__/__/__
9. Adenosine: Pharmacokinetics; dose; and route of administration
__/__/__
10. Major side effects of adenosine
__/__/__
XIII.Bioengineering and Monitoring:
70
1. Predictive scoring systems for the severity of illness in the ICU
__/__/__
XIV.Ethical and Legal Aspects of Critical Care Medicine:
1. Ethic in the ICU
__/__/__
a. Informed consent
__/__/__
b. Withholding and withdrawal of life support
__/__/__
c. Requests for futile therapies
__/__/__
XV.Administrative and Management Principles and Techniques:
1. Prognosis of common medical conditions observed in the ICU
__/__/__
DIVISION OF PULMONARY AND CRITICAL CARE MEDICINE
POLICY ON RECRUITMENT AND APPOINTMENT OF FELLOWS
PURPOSE
To define the requirements and procedures for the recruitment and appointment of
residents to training programs sponsored by the University of Arkansas College of
Medicine.
POLICY
The recruitment and appointment of residents to training programs is based on the
requirements of the Accreditation Council for Graduate Medical Education.
Each
training program will comply with the following procedures in selecting eligible
residents:
ELIGIBILITY
71
To be eligible for appointment to a training program, an applicant must have excellent
written and spoken English language and communication skills and one of the following
qualifications:
1. Graduate of a medical school in the United States or Canada accredited by the
Liaison Committee on Medical Education (LCME).
2. Graduate of a college of osteopathic medicine in the United States accredited by
the American Osteopathic Association (AOA).
3. Graduate of a medical school outside the United States or Canada who meets one
of the following qualifications:
a. Has received a currently valid certificate from the Educational Commission
for International Medical Graduates
b. Has a full and unrestricted license to practice medicine in the US licensing
jurisdiction.
4. Graduate of a medical school outside the United States who has completed a Fifth
Pathway program provided by an LCME-accredited medical school.
5. Successful completion of an accredited 3 year Internal Medicine Residency; eligible
or certified in Internal Medicine by the American Board of Internal Medicine.
The UAMS Medical Center is a drug free work place, each fellow must pass a preemployment drug test and participate in the UAMS Drug Testing Program (UAMS policy
3.1.14)
SELECTION OF FELLOWS IN PULMONARY/CRITICAL CARE
MEDICINE
The
selection
of
internal
medicine
residents
for
subspecialty
training
in
Pulmonary/Critical Care Medicine is the responsibility of the Division of Pulmonary and
Critical Care Medicine Director, Program Director and Faculty.
Applications are
screened by the Program Director and qualified candidates are invited for interviews.
Only candidates who are currently in or have completed accredited U.S. Internal
72
Medicine residency programs are considered. A candidate’s record of past academic
and clinical performance, proficiency in English (spoken and written), letters of
recommendation, and the applicant’s commitment to scholarship and life long self
learning are considered when inviting applicants for a personal interview. A premium is
placed on the information gained during the personal interview. Faculty who interview a
fellowship applicant complete a written evaluation.
The division director and program
director are responsible for verifying the eligibility requirements of applicants (including
English language proficiency). The division faculty meet to discuss the ranking order.
The final rank list order is determined by the Program director. Fellowship positions
are selected through the National Residency Matching Program (NRMP) unless there
are mitigating circumstances.
APPOINTMENT/REGISTRATION
To be appointed to the Pulmonary/CCM Fellowship Training Program, a resident must
be selected by the Pulmonary/CCM faculty (typically through the NRMP), have a
negative drug test and complete and return the following documents to the Director of
House staff Records:
1. Agreement (contract)
2. Medical Records Agreements
3. Attestation about policies and procedures
4. Practitioner Health Questionnaire
5. Employee Drug Free Awareness Statement
6. House staff Medical Screening Form
7. Postdoctoral Medical Educational Biographical Data Form
8. Copy of Current EFCMG certificate (if applicable)
9. Current Visa (if applicable)
PROCEDURE
73
1. Annually the Training Program Director or Program Coordinator submits to the
Director of House staff records of verification that fellows in the Pulmonary/CCM
fellowship program meet the eligibility requirements described above.
2. The Graduate Medical Education Committee monitors the compliance of the
Pulmonary/CCM Fellowship with its policy, including a periodic review of the
training program’s written criteria and guidelines for selection of fellows and a
description of a training program’s applicant pool, demographic characteristics,
and selection procedures.
DIVISION OF PULMONARY AND CRITICAL CARE MEDICINE
POLICY ON EVALUATION AND PROMOTION
PURPOSE
To describe the policy and procedures pertaining to evaluation and promotion of
residents
DEFINITIONS
Promotion is advancement based on merit to a higher rank or title. Failure to perform
at an acceptable level in the period of current appointment means that an individual will
not be promoted. A non-promotion does not automatically mean non-reappointment or
dismissal, but merely that the resident will not be advanced to the next level of
appointment at the completion of the contract period.
Non-promotion means that the resident failed to perform at an acceptable level in the
period of current appointment or cannot reasonably function satisfactorily at the next
level and is not advanced to a higher rank or title.
Non-reappointment means that a resident is not offered the next successive contract
for appointment at the end of the current appointment period (usually June 30). Non-
74
reappointment is not considered a dismissal and has no connotation of unsatisfactory
performance.
POLICY
The evaluation and promotion of Pulmonary/CCM fellows is the responsibility of each
training program director and department chair. The program director must establish
and implement formal written criteria and processes for the evaluation and promotion of
residents according to the procedure below
Training program director must notify each residents of the decision to non-promote or
non-reappoint by a written notice at least 4 months prior (usually March 1) to the
expiration of the current period of appointment, regardless of PGY level of the resident.
A resident involved in non-reappointment or non-promotion has the right to appeal
according to the GME Committee policy Adjudication of Residents Grievances.
The Graduate Medical Education Committee, through its internal review process, will
monitor each training program’s written policies, procedures and guidelines for
evaluation and promotion of its residents.
PROCEDURE
The program director, with participation of members of the faculty shall:
1. Evaluate the knowledge, skills and professional growth of the residents, using
appropriate written criteria and processes to determine advancement in the
program.
The evaluation is done semi-annually.
The written criteria and
processes for evaluation should be communicated to each resident.
2. Communicate (via New Innovations) each evaluation to the resident in a timely
manner and review all clinical evaluations.
75
3. Maintain a permanent record of evaluation for each resident and have it
accessible to the fellow and other authorized personnel including the internal
review panel.
4. Advance fellow to positions of higher responsibility only on the basis of
evidence of their satisfactory progressive scholarship and professional growth.
5. Notify each resident of the decision to promote, not promote or non-reappoint by
a written notice at least 4 months prior to the expiration of the current period of
appointment.
6. Provide a final written evaluation for each resident who completes the program
as part of the resident’s permanent record maintained by the department.
EVALUATION OF FELLOWS IN PULMONARY AND CRITICAL CARE
MEDICINE
At the end of each month, the faculty members who were involved with the fellow during
that rotation completes an evaluation and is responsible for communicating with the
fellow about his/her performance. The Fellowship Training Committee (Drs. Erbland,
Johnson and Mireles) meets on an annual basis to review and discuss the fellows’
evaluations. The comments of this committee are discussed at a faculty meeting. The
Division or Program Director meets every 6 months with each fellow and reviews
his/her progress based on the evaluations, the committee comments, and his/her own
assessment. A written documentation is placed in their record. A fellow’s evaluation
folder is available for his/her review at any time in the UAMS Pulmonary Office.
Faculty also discuss and evaluate the fellows’ procedural skills.
The Fellowship
Training Committee reviews procedural competence based on faculty evaluations,
procedures database information and personal observation.
Commendations or
deficiencies are noted in the semiannual review and discussed with the fellow.
76
PROMOTION, NON-PROMOTION, AND NON-REAPPOINTMENT OF
RESIDENTS IN PULMONARY AND CRITICAL CARE MEDICINE
Advancement of fellows to the next level of training is the responsibility of the division
chief and program director. The training program director must notify each resident of
the decision to non-promote or non-reappoint by a written notice sent at least 4 months
(usually March 1) prior to the expiration of the current period of appointment regardless
of the PGY level of the resident.
Non-promotion of a fellow may occur for one of 2 causes: 1) documented evidence of
inadequate performance and/or 2) unacceptable or inappropriate attitude or behavior.
When a fellow’s performance and/or conduct is considered sufficiently unsatisfactory
that non-promotion is being considered, notice will be given to the fellow orally and in
writing. The division director and/or program director will meet with the fellow and
outline recommendations to correct the problem(s). If the situation is not improved
within a reasonable period of time the fellow will not be promoted.
Immediate dismissal can occur at anytime without prior notice in instances of gross
misconduct (e.g., theft of money or property; physical violence directed at an employee,
visitor or patient; use of alcohol/drugs while on duty).
A resident involved in a non-reappointment or non-promotion has a right to appeal
according to the Policy of the Graduate Medical Education Committee on Adjudication
of Residents Grievances.
PULMONARY/CCM FELLOWSHIP
TRAINING PROGRAM PROCEDURE
ON RAISING AND RESOLVING ISSUES OF CONCERN
At times various issues resulting from miscommunication, stress, or inappropriate
behavior may arise.
In compliance with the UAMS College of Medicine Graduate
Medical Education Committee policy on raising and resolving issues in a confidential
manner, the following guidelines apply within the Pulmonary/CCM Fellowship Training
Program.
77
1. A fellow should discuss the concern with the supervising attending physician or
the fellow’s assigned faculty advisor or research mentor.
2. If the above discussion does not resolve the concern, the fellow should meet
with the Program Director or Division Chairperson.
3. If the issue cannot be resolved by the Program Director, the fellow should
contact the Chair or any member of the Resident Council or the Associate Dean
for Graduate Medical Education. Any of these individuals can advise the fellow
about options for resolution of the concern.
4. For issues that are extremely serious and for which confidentiality is of the
utmost importance, the fellow may seek assistance directly from the Program
Director and/or the Associate Dean for Graduate Medical Education.
5. Should a fellow believe that a rule, procedure or policy has been applied to
him/her in an unfair or inequitable manner or that he/she has been the subject
of unfair or improper treatment, that fellow should follow the procedure(s)
outlined in the Graduate Medical Education Committee Policy on Adjudication of
Resident Grievances.
DESCRIPTION OF SUPERVISORY
LINE OF RESPONSIBILITY
PULMONARY/CCM FELLOWSHIP TRAINING PROGRAM
In compliance with the UAMS College of Medicine Graduate Medical Education
Committee policy on supervisory lines of responsibility the following apply to the
supervision for the care of patients within the Department of Internal Medicine and
Division of Pulmonary and Critical Care Medicine:
1. Attending faculty physician supervision is provided at all times appropriate to
the skill level of the fellow on the service/rotation.
2. Specific lines of responsibility for patient care are included in the written
description of each service/rotation, which are reviewed with the fellow at the
beginning of the service/rotation.
In general, the Pulmonary/CCM fellow
oversees the Internal Medicine residents and interns. The attending faculty
78
physician oversees the entire team and is available at all times in person or by
telephone.
3. Call responsibilities and supervision are reviewed with the fellow at the
beginning of each rotation or if/when there is a change in the call schedule.
The specific dates, supervision and contact numbers are documented on the
written (and computerized) call schedule which is distributed each month to all
residents/fellows, and attending faculty physicians.
PULMONARY/CCM FELLOWSHIP TRAINING PROGRAM POLICY ON
WORK HOURS, WORK ENVIRONMENT, AND MOONLIGHTING
In compliance with the UAMS College of Medicine Graduate Medical Education
Committee policies on work hours/work environment and moonlighting and considering
that the care of patient and educational clinical duties are of the highest priority, the
following guidelines apply:
WORK HOURS
1. work week – each fellow shall work no more than an average maximum of
80 hours of assigned clinical duties per week
2. days off – each fellow shall be given a monthly average of 1 day in 7 free
from clinical duties and expectations
3. in-house call – (if applicable) – each fellow shall be on in-house call no
more that an average of every 3 rd night.
The Pulmonary/CCM fellow is expected to be on duty during normal working hours
(8:00 a.m. – 5:00 p.m.), Monday through Friday. Additional work hours include on-call
duties. Night, weekend and holiday call schedules are formulated by the third year
Pulmonary/CCM fellow(s). Fellows must be available by telephone or pager while oncall at night and during the weekend. Specific call schedules and responsibilities are
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delineated in written goals/objectives of each rotation and are reviewed with the fellow
at the beginning of the rotation.
Exceptions to the above work hours include official holidays and while on approved
annual, sick, or educational leave.
WORK ENVIRONMENT
1. supervision: staff physician supervision is provided at all times appropriate to
the skill level of the resident. A specific staff physician supervisor is noted on
the goals/ objectives of each rotation or the call schedule. Decisions made by
the resident/fellow while on-call under the supervision of the responsible faculty
staff member. The progressive increase in the knowledge and ability of the
resident/fellow when handling these decisions is an important step toward
becoming a confident specialist.
2. meals: meals are available for those residents/fellows who provide 12
consecutive hours of in-house call.
3. call rooms: call rooms provided for all residents who take in-house call.
4. ancillary support: adequate ancillary support for patient care is provided.
Except in unusually circumstances, providing ancillary support is not the
resident/fellow’s responsibility except for specific educational objectives or as
necessary for patient care. This is defined as, but not limited to, the following:
drawing blood, obtaining EKGs, transporting patients, securing medical records,
securing test results, completing forms or order test and studies, monitoring
patients after procedures.
5. Other work environment benefits: you may want to add department-funded
benefits such as educational materials, travel to meetings etc.
MOONLIGHTING
In order to be eligible to moonlight, Pulmonary/CCM fellows must follow the procedures
outlined in the UAMS College of Medicine Graduate Medical Education Committee
policy, Moonlighting and Malpractice Insurance Coverage while Moonlighting.
Pulmonary/CCM Fellows are not required to moonlight.
Pulmonary/CCM fellowship
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training is a full time endeavor and is not compatible with non-academic extracurricular
employment. Moonlighting is allowed only with the written permission of the program
director. This information is contained in the fellow’s file.
Moonlighting malpractice
insurance is the sole responsibility of the fellow. It is the responsibility of the fellow and
/or the hiring facility to determine if the fellow has the appropriate skills, credentials,
and liability coverage.
All moonlighting hours must be counted as part of the 80 hour work week limit on duty
hours.
Moonlighting privileges will be withdrawn if the fellow’s performance in the
Pulmonary/CCM training program is unsatisfactory.
If permission to moonlight is
withdrawn by the program director, the obligation to notify an outside employer is the
sole responsibility of the fellow.
Fellows will be subject to dismissal from the program for the following:
1. moonlighting without written approval of the program director,
2. continuing to moonlight after writer permission to do so is withdrawn,
3. using the University Hospital’s or Arkansas Children’s Hospital DEA number
while moonlighting.
Request to Moonlight
In order to be eligible to moonlight, Pulmonary/CCM fellows must follow the procedures outlined in
the UAMS College of Medicine Graduate Medical Education Committee policy, Moonlighting and
Malpractice Insurance Coverage while Moonlighting. Pulmonary/CCM fellows are not required to
moonlight. Pulmonary/CCM fellowship training is a full time endeavor and is not compatible with
non-academic extracurricular employment. Moonlighting is allowed only with the written permission
of the program director. This information is contained in the fellow’s file. Moonlighting malpractice
insurance is the sole responsibility of the fellow. It is the responsibility of the fellow and/or the hiring
facility to determine if the fellow has the appropriate skills, credentials, and liability coverage.
Moonlighting privileges will be withdrawn if the fellow’s performance in the Pulmonary/CCM training
program is unsatisfactory. If permission to moonlight is withdrawn by the program director, the
obligation to notify an outside employer is the sole responsibility of the fellow.
Fellows will be subject to dismissal from the program for the following:
a. Moonlighting without written approval of the program director,
b. Continuing to moonlight after permission to do so is withdrawn,
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c.
Using the University Hospital’s or Arkansas Children’s Hospital DEA number while
moonlighting.
As a fellow in the Pulmonary/CCM training program, I understand and will abide by the above
moonlighting requirements. I attest that moonlighting will not interfere with my ability to achieve the
goals and objectives of my training program. I request permission to moonlight.
Facility/Employer:__________________________________________________________
Dates/frequency of moonlighting:______________________________________________
Fellow’s Name (print)
Signature
Signature of Program Director
Date
Date
DIVISION OF PULMONARY AND CRITICAL CARE MEDICINE POLICY
ON ACADEMIC AND OTHER DISCIPLINARY ACTIONS
(PROBATION, SUSPENSION AND DISMISSAL)
PURPOSE
To define the circumstances which may result in probation, suspension or dismissal
from the residency program and to establish fair policies and procedures for academic
or other disciplinary actions taken against residents.
The position of resident (the term ―resident‖ applies to interns, residents, and fellows)
presents the dual aspects of a student in post-graduate training and a participant in the
delivery of patient care. A resident’s continuation in the training program is dependent
upon satisfactory professional standards in the care of patients. Behavior that reflects
poorly on professional standards, ethics, and collegiality are all components of a
resident’s academic evaluation.
DEFINITION
PROBATION: a trial period in which a resident is permitted to redeem academic
performance of behavioral conduct that does not meet the standard of the training
program.
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SUSPENSION: a period of time in which a resident is not allowed to take part in all or
some of the activities of the training program. Time spent on suspension may not be
counted toward the completion of program requirements.
DISMISSAL: the condition in which a resident is directed to leave the training program,
with no award of credit for the current training year, termination of the resident’s
Agreement of Appointment, and termination of all association with the College of
Medicine and its participating teaching hospitals.
POLICY
Each Training Program director must implement written criteria and processes for
academic and other disciplinary actions within the program including, but not limited to,
probation suspension and dismissal from the residency program. The specific actions
of probation, suspension, and dismissal must follow the guidelines listed below. The
particular administrative action imposed shall be based on individual circumstances
and will not necessarily follow the sequential order in which they are described below.
A resident involved in any of the administrative actions of probation, suspension,
dismissal has the right to appeal according to the GME Committee Policy, 1.410,
Adjudication of Resident Grievances.
PROCEDURE
PROBATION
1.
A resident may be placed on probation by a Training Program Director for
reasons including, but not limited to any of the following:
a. failure to meet the performance standards of an
individual rotation;
b. failure to meet the performance standards of the
training program;
c. failure to comply with the policies and procedures of the GME Committee, the
UAMS Medical Center, or the participating
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institutions;
d. misconduct that infringes on the principles and guidelines set forth by the
training program;
e. documented and recurrent failure to complete medical records in a timely and
appropriate manner
f. when reasonably documented professional misconduct or ethical charges are
brought against a resident which bear on his/her fitness to participate in the
training program.
2.
When a resident is placed on probation, the Training Program Director shall
notify the resident in writing in a timely manner, usually within a week of the
notification of probation. The written statement of probation will include a length
of time in which the resident must correct the deficiency or problem, the specific
remedial steps and the consequences of noncompliance with the remediation. A
copy of this written statement of probation shall be forwarded to the Associate
Dean For Graduate Medical Education.
3.
Based upon a resident’s compliance with the remedial steps and other
performance during probation, a resident may be:
a. continued on probation;
b. removed from probation;
c. placed on suspension; or
d. dismissed from the residency program
SUSPENSION
1.
A resident may be suspended from a residency program for reasons including,
but not limited, to any of the following:
a. failure to meet the requirements of probation;
b. failure to meet the performance standards of the training program;
c. failure to comply with the policies and procedures of the GME Committee, the
UAMS Medical Center, or the participating institutions;
d. misconduct that infringes on the principles and guidelines set forth by the
training program;
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e. documented and recurrent failure to complete medical records in a timely and
appropriate manner;
f. when reasonably documented professional misconduct or ethical charges are
brought against a resident which bear on his/her fitness to participate in the
training program;
g. when reasonably documented legal charges have been brought against a
resident which bear on his/her fitness to participate in the training program;
h. if a resident is deemed an immediate danger to patients, himself or herself or
to others;
i. if a resident fails to comply with the medical licensure laws of the state of
Arkansas.
2. When a resident is suspended, the Training Program Director shall notify the
resident with a written statement of suspension to include:
a.
reasons for the action;
b.
appropriate measures to assure satisfactory resolution of the problem(s);
c.
activities of the program in which the resident may and may not participate;
d.
the date the suspension becomes effective;
e. consequences of non-compliance with the terms of the suspension;
f. whether or not the resident is required to spend additional time in training to
compensate for the period of suspension and be eligible for certification for
a full training year.
A copy of the statement of suspension shall be forwarded to the Associate Dean for
Graduate Medical Education and the Director of Housestaff Records.
3. During the suspension, the resident will be placed on ―administrative leave‖, with or
without pay as appropriate depending on the circumstances.
4. At any time during or after the suspension, resident may be:
a. reinstated with no qualifications;
b. reinstated on probation;
c. continued on suspension; or
d. dismissed from the program.
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DISMISSAL
1. Dismissal from a residency program may occur for reasons including, but not limited
to, any of the following;
a. failure to meet the performance standards of the training program;
b. failure to comply with the policies and procedures of the GME Committee, the
UAMS Medical Center, or the participating institutions;
c. illegal conduct;
d.
unethical conduct;
e. performance and behavior which compromise the welfare of patients, self or
others;
f. failure to comply with the medical licensure laws of the State of Arkansas;
g. inability of the resident to pass the requisite examinations for licensure to
practice medicine in the United States.
2. The Training Program Director shall contact the Associate Dean for Graduate
Medical Education and provide written documentation that led to the proposed
action.
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