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.

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DIVISION OF PULMONARY AND CRITICAL CARE MEDICINE

KEY FACULTY PAGER

Anderson, Paula J., M.D. 688-6604

Professor of Medicine

Bartter, Thaddeus, M.D. 501.366.2593 phone

Professor of Medicine

Erbland, Marcia L., M.D. 688-6505

Professor of Medicine, Program Director

Johnson, Larry G. M.D. 688-6322

Professor of Medicine, Division Director

Hiller, F. Charles M.D. 688-6035

Professor of Medicine

Joshi, Manish, M. D. 688-6097

Assistant Professor of Medicine

Mireles-Cabodevila, Eduardo, M.D. 688-6411

Assistant Professor of Medicine

Reddy, Raghu M., M.D. 688-6290

Assistant Professor of Medicine

Patel, Hiren., M.D. 688-6658

Instructor of Pulmonary Medicine

FELLOWS

Badireddi, Sridhar 688-2610

Bhaskar, Nutan 405-6745

Jagana, Rajani 688-6448

Khan, Junaid 688-2475

Meena, Nikhil Kumar 688-2130

Mohammad, Khalid 405-6744

Siddiqui, Mohammad, 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:

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 3

rd 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

Pulm/CCM - Consults – 5 months MICU – 3 months Research – 3 months

Pulm Diag/ Sleep

1 mo.

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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 in-

patient 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 on-

call 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 in-

person. 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 2nd

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 1st and 3rd Tuesday of the month and the

remaining 3 fellows are assigned the 2nd

and 4th Tuesday of the month. There is a bi-

monthly pulmonary clinic at the VAMC on Thursday afternoon; 3 fellows attend every

2nd

Thursday of the month and the other 3 fellows attend every 4th 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 4

th

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 wi ll

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.new-

innov.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 semi-

annual 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

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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.

20

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. No more than 2 fellows can be on leave during the same time

period. 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

21

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

22

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.

23

PULMONARY STAFF

NAME PAGER # TELEPHONE FAX OFFICE LOCATION SLOT#

FACULTY 686-7893 555

Anderson, Paula 688-6604 686-5525 UAMS 3S14c

Bartter, Thaddeus 366-2593 UAMS Barton 4R/29 555

Bartter, Teka 410-0551 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

Patil, Hiren V. 688-6658 257-5786 LRVA 6A132A VA-111-P

FELLOWS 686-5525 686-7893 555

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 688-9334 686-5525 UAMS 3s14g 555 OFFICE STAFF 686-7893 555

Robinson, A. Doris 686-5679 UAMS 3S14

Oswald, Shirley 686-5526 UAMS 3S14

Baker, Cher (trbaker@uams.edu) 686-5525 UAMS3S14

Abraham, Alicia (VA) 257-5786 257-5787 LRVA 5C/144 VA111-P

Shaw, Cyndi – Stukenburg, Al 257-5866 257-5867 LRVA 6a/116 111-LR

PFT LAB 555

Taggart, Adam 416-7019 cell # 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 257-5634 LRVA 5A/102

BRONCOSCOPY 686-6407

Kagebein, Susie – UAMS 688-2834 870-830-6787

Broncoscopy Lab RM # 1 526-8817

Jenkins, Peggy – VA 257-1000x55827

ACRC

Jones, Shirley A. 526-6990X8702 296-1181 ACRC 7th Floor 721-2

SLEEP LAB 257-6063

Carmical, Paul W. 257-6064 LRVA 7C/110

Shelton, Judith 257-6064 LRVA 7C/110

OUTPATIENT CLINIC 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 296-1170, 1246

MEDICAL RECORDS 686-6038 524

TB Clinic 280-3110/ 3111 280-3180

Bates, Joseph N/A 661-2398 AR Dept of Health

Patil, Naveen 661-2152 AR Dept of Health

24

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.

25

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) Pathologic Materials

(X) Radiological studies (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

26

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 non-

Medicine 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

27

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.

28

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

29

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)

30

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 __/__/__

31

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 __/__/__

32

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 __/__/__

33

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

__/__/__

34

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 __/__/__

35

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 __/__/__

36

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

__/__/__

37

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 __/__/__

38

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 __/__/__

39

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 __/__/__

40

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

41

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

__/__/__

42

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)

43

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

44

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)

45

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

46

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)

47

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

48

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

49

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

50

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

51

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

52

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

53

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

54

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

55

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 (high-

risk 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,

56

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 MICU-

related 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)

57

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, 2

nd and 3

rd year fellows.

During the MICU rotations, fellows are evaluated on their ability to appropriately

perform the 6 clinical competencies listed below.

58

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 the diagnostic and/or

therapeutic procedures within the subspecialty. This includes the ability to

perform the necessary manual skills, 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

59

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

60

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)

61

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)

__/__/__

62

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

__/__/__

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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

__/__/__

64

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 __/__/__

65

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 __/__/__

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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 __/__/__

67

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:

1. Etiology of hypercalcemia __/__/__

2. Hypercalcemia of malignancy __/__/__

3. Diagnostic approach to hypercalcemia __/__/__

4. Treatment of hypercalcemia __/__/__

j. 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:

68

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 __/__/__

69

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 __/__/__

70

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:

71

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

72

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 pre-

employment 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

73

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

74

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-

75

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.

76

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.

77

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.

78

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

79

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 3rd 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 on-

call at night and during the weekend. Specific call schedules and responsibilities are

80

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

81

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,

82

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 Date

Signature of Program Director 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.