Curriculum Rotation Descripton

submenu

During the first year of fellowship 2 months are spent in the University MICU and one month on UMMC general pulmonary consults. Second or third year Fellows will also do one month of pulmonary consults. In general, there will be 2 Fellows at the University.

University of Minnesota Medical Center

During the first year of fellowship 2 months are spent in the University MICU and one month on UMMC general pulmonary consults. Second or third year Fellows will also do one month of pulmonary consults. In general, there will be 2 Fellows at the University.

Pulmonary Consult

Pulmonary Consult

Pulmonary Inpatient and Outpatient Consults
The Consult Team covers all NON– 4D and 4E consults at UMMC (including 4B-BMT), and ALL consults at UMMC Riverside campus—including ICU if we are specifically asked (but make sure they want US to see the patient and not the intensivist service already at Riverside). We also cover urgent outpatient consults, such as BMT Clinic, Pulmonary Clinic, etc.

Consults are called directly to the Resident or Fellow by the ward secretary or primary team. If the team is requesting a bronchoscopy, please check that all necessary labs are obtained, make the patient NPO, and alert endoscopy and your attending regarding a possible bronch. All patients must have a consent, a procedure note in Provation (EMR) and post-procedure orders. There is often a resident/student on this rotation as well. The Fellow is expected to act as the most senior house staff on the team: organizing and distributing consults and providing education to the residents and students.

Rounding: The timing of rounds is at the discretion of each Pulmonary Attending, since they all have varying schedules. It is also recommended that the notes are completed as much as possible prior to rounding.

PFTs: Fellows read PFTs during their Pulmonary UMMC Consult rotation. The PFTs are viewed on a computer in the Pulmonary office, read there, corrected and signed. Although there is an automatic computer-generated reading, this is frequently wrong! (Thus the manual verification.)

There is a faculty member assigned to over-read PFTs and add the final signature. Please ask your staff to give you a quick run-through to get you started. DURING YOUR FIRST WEEK YOU SHOULD READ THE PFTS WITH THE PFT FACULTY PERSON. PLEASE ARRANGE THIS.

For the Fellows reading PFTs at UMMC, there is a turn-around time of 72 hours for the official interpretation to be completed. When you interpret the PFTs on the computer, change the status to FINAL REVIEW (not COMPLETED) when you are done. The Attending will then review and change status to COMPLETED-POSTED-LOCKED. The Attending cannot modify the results if you choose COMPLETED status!

PFT Tutorial: You will get a tutorial on PFT interpretation; it includes a small test administered by Ed Corazalla, Technical Director of the Pulmonary Function Laboratory. You MUST COMPLETE this within the first 3 days of starting consults. This is important! Contact Ed to arrange your tutorial.

Transplant Bronchs: The Consult Team performs transplant bronchs on outpatients (and occasionally inpatients) on Tuesdays and Wednesdays from 10 – 12. The CF/Transplant Teams perform these on Tuesdays and Wednesdays from 8 – 10. These are optional, but are a great opportunity to get a lot of TBBx experience. All patients must have a consent, a procedure note in Provation (EMR), and post-procedure orders.

Urgent Outpatient Consults: First check with the Pulmonary Nurse in Medicine Clinic (612) 626-0191 to see if the patient can be seen in the Fellows’ Clinic. If not, contact your Attending regarding scheduling a time to see the patient.

Medical Intensive Care Unit

Medical Intensive Care Unit

Medical Intensive Care Unit
The MICU is a closed unit that consists of 3 medical students doing their MED II rotation for 3 weeks, 1 medical Intern, 2 medical Residents (one month rotations), a full-time weekdays-only Nurse Practitioner, Fellow and Attending (two week rotations). An ICU Resident is in the unit from 6:30 am to 4-6 pm daily and a second one from noon to midnight 6 days a week with post-midnight coverage by a subspecialty nightfloat resident+intern team daily. About 40% of the time there is also a Family Practice Resident who will act at the level of a Medicine Intern. All of the patients in the MICU are our primary patients except “boarding” patients that have improved enough to no longer require ICU care but haven’t been able to be transferred up to the floor because of lack of beds. The Fellow’s role in the MICU is to supervise the Residents’ and students’ patient care and procedures and perform critical care consults in other adult ICUs (except BMT patients which are seen by the Consult Team) and perform bronchoscopies and intubations. For all other procedures it is desirable for the HO and students to get experience and the Fellow should teach and supervise the procedure but step in if initial attempts are unsuccessful or the patient needs the intervention immediately. In addition, the Fellow should assume a role of “teacher and supervisor” for the HO and students, including practical lectures and bedside vent demonstrations, distributing pertinent articles. The Fellow should review patient’s DDX, assessments and plans with the HO but should not assume the role of the HO. The most important attribute/skill to have to be an effective clinical Fellow at the University Hospital is to be very flexible and available for direct care of unstable patients at any time.

We admit patients daily. Fellows might have to come in and do ICU admissions if the nightfloat team has filled to their capacity of 6 patients.

We are responsible for all procedures: central lines, swan-ganz catheters, bronchoscopies, arterial lines, LP, paracentesis, thoracentesis. The Fellow coordinates all procedures. The Attending must be present for the critical portion of the procedure.

An ultrasound is available and should be used for central line insertions.

Other procedures: intubation. DL or RSI intubations are at the Attendings’ discretion and are frequently done with anesthesia. We often intubate patients over a bronchoscope without paralysis because they will get a bronchoscopic exam anyway. We sometimes place feeding tubes under fluoroscopy.

Bronchoscopies, intubations, feeding tube placements are assisted by the 4C RT assigned to the procedure room (Usually Paul or Bill). All patients must have a consent, a procedure note in Provation (EMR) and post-procedure orders.

Rounding: pre-rounds by HO--6:30-7:45 am, Xray rounds--7:45 am, work rounds--8:00 am-12:00 (variable by Attending and number and severity of patients), informal rounds with residents to reassess unstable patients--around 3-4pm.

ICU Rounding team: students, HO, Fellow, Attending, PharmD, pharmacist, pharmacy student, charge nurse, RT (usually in unit, doesn’t round with team unless needed)

All admits to the ICU must be pre-approved by the ICU Attending - the Attending then contacts the Fellow and HO. IF Fellows are called regarding admissions please refer it to the Attending.

Transfers out of the ICU: patients aren’t “accepted” by the floor team until the Attending contacts the accepting Attending; then the ICU HO can call the requisite floor HO. Fellows usually do not need to be involved.

Time off: The Fellow is on every other weekend. The Resident and Intern each get one day off a week.

Weekend Bronchoscopies: The pathologist on call needs to be called to process and look at the cytology/pathology for all bronchs after 3pm Friday and those performed on Saturday and Sunday.

Critical Care Consults: NOTE: these are done by the MICU Fellow/team

Minneapolis VA Health Care System (MVAHCS)

In contrast to the other hospital rotations, the three months at the Minneapolis VA will be entirely spent as a pulmonary consultant, focusing on the assessment and management of pulmonary diseases with little time spent in the ICU. The Minneapolis VA is both a primary care provider and a tertiary referral hospital for veterans, serving a five-state upper Midwest network. Consequently, during these three months, Fellows will see the gamut of pulmonary diseases ranging from typical outpatient problems to complex referral issues.

Consult Service

Consult Service

The Consult Team is composed of the Fellow, one or two Medical Residents, and one of the eight Pulmonary Staff who rotate through at one-week intervals. The Consult Service is predominantly outpatient-based, with an average of 6 to 8 new consult patients scheduled each day in the Pulmonary Evaluation Clinic. We also engage in video telemedicine consults to remote VA clinic sites within our large geographic catchment area. The Consult Team is also responsible for inpatient consults, averaging 2 or 3 consults per day from a wide range of settings (e.g. medical and surgical wards, spinal cord injury unit, polytrauma unit, community living center).

Procedures
During your three month rotation, you will have the opportunity to perform bronchoscopies and pleural procedures. The vast majority of these are performed as outpatient procedures; however, you will have the opportunity to perform bronchoscopy and pleural procedures on patients from the wards and ICU. The VA rotation is your primary opportunity to acquire skills for endobronchial procedures. You will also have opportunities to perform navigational bronchoscopies for peripheral lung lesions and central lymph nodes. Bronchoscopies are performed in the Pulmonary Bronchoscopy Suite under the supervision of the Consult attending and are staffed by a pulmonary sedation nurse and a respiratory therapist.

Other Responsibilities
The Fellow is responsible for triaging incoming pulmonary consultation requests and determining which requests will require a face-to-face visit, versus which can be completed using electronic consultation through the VA's robust electronic medical record system. Fellows also interpret pulmonary function testing and have the opportunity to learn about portable sleep testing and treatment of complex sleep-disordered breathing.

Weekly Schedule
Monday – Friday: 8:00 am to 5:00 pm: Consults in the outpatient clinic and inpatient units, procedures, consult triage and teaching.

  • Wednesday: 7:30 am: Pulmonary fellows weekly conference (rotating site schedule).
  • Wednesday: 12:00 pm: Medicine M&M conference.
  • Thursday: 12:00 pm: Medicine Research Conference
  • Thursday: 1:00 pm: Pulmonary Continuity Clinic: Pulmonary Clinic is attended by the Fellow, Residents, and all Pulmonary Staff. This is where most follow-up cases will be seen (the Evaluation Clinic is primarily new consultation patients).
  • Friday: 8:00 am: Multidisciplinary Chest Conference. Attended by the Consult Team, Pulmonary Staff, Thoracic Surgery, Medical Oncology, Radiation Oncology, Radiology and Nuclear Medicine. Cases of suspected/confirmed lung cancer and other pulmonary diseases are discussed. The Pulmonary Fellow is responsible for ensuring that Pulmonary service cases are presented succinctly (by themselves or by the Residents) and that decisions are recorded in the chart.
  • Friday: 12:00 pm: Medicine Grand Rounds.

Hennepin County Medical Center (HCMC)

During the HCMC rotations, the Fellow will spend 1 month on the HCMC Pulmonary Consult Service, 1 month in the HCMC MICU and 1 month at the Methodist Hospital MICU. The experience is broad and provides exposure to all aspects of respiratory medicine: ICU, consults, clinic, sleep, exercise and PFT lab.

Pulmonary Consults

Pulmonary Consults

Pulmonary Fellow’s Role On The HCMC Consult Service
The Pulmonary Consult Service is composed of the Pulmonary Staff, 1-2 Residents and 0-2 medical students. The Fellow is responsible for organizing consult rounds, seeing and discussing all new consults and followups with the Consult Residents/students, educating the Residents/students rotating on the Pulmonary Consult Service regarding issues pertaining to pulmonary medicine, ensuring communication of Pulmonary's recommendations to the Primary Team, arranging and performing bronchoscopies, and performance of or supervision of residents performing other pulmonary procedures (chest tubes, thoracenteses).

Daily Schedule/Rounds
See new in-patient consults and follow ups 9:00-10:30 (approximate)

Consult Rounds
10:30 - 12:00 and afternoon, either before or after clinic (variable).

Clinic
Pulmonary Clinic (Located on G-1) - All day Monday, Tuesday, and Wednesday and Friday at 1:00 p.m. On M/W/F the clinic is a new patient clinic staffed by the Consult Attending. The Pulmonary Staff also have continuity clinics at the same time/location on M/T/W; the Fellow is expected to take this opportunity to see some of these patients as well, especially if the New Patient Clinic or the Consult Service is slow.

Because procedures or other pressing concerns may occur at these times, the Fellow may not always get to clinic. However, when possible, clinic should be attended.

Many interesting problems, both new and old, are seen in the outpatient area and the Fellow should be an integral part of the decision-making process here.

Procedures
The Fellow is responsible for bronchs, chest tubes, Cope biopsies, and difficult thoracentesis. The Fellow may supervise thoracentesis if the G-1 or G-2 has not had much experience. As the Fellow gains experience with chest tubes, he/she will also supervise the G-2. (Should discuss placement of chest tubes with Pulmonary Staff prior to procedure, unless emergent).

On-Call
While on the Consult Rotation, the Fellow will take call in the HCMC MICU every 2-3 weekends, and about 1-2 weeknights/week. While on call, the Fellow is the acting Critical Care Fellow, and the expectations/responsibilities are the same (see HCMC MICU rotation).

Medical Intensive Care Unit

Medical Intensive Care Unit

Pulmonary Fellow’s Role in the HCMC MICU
During their month in HCMC MICU, the PF assumes the role of the HCMC Critical Care Fellow. This role includes evaluation and discussion with the admitting team of all new admissions and patients with active problems in the MICU, supervision of residents performing ICU procedures, and education of the residents rotating on the MICU service regarding issues pertaining to intensive care medicine. For patients on the MICU service the PF is not required to write notes.

The PF is also responsible for providing ICU consultation on all patients on the Nephrology Service in the MICU (in general these are the only patients in the MICU that are not on the MICU service, but they tend to be sick and complex). The Fellow should fill out a consultation form and staff the new Nephrology Service patients with the On Call MICU Staff. Rarely, critically ill patients on the Neurology Service will board in the MICU; they should also receive a critical care consultation.

Patient Rounds
On weekdays there are 2 MICU staff and 4 MICU teams (2 teams per staff). The Fellow will typically round in the morning with the staff and 2 teams that are post-call. In this way the Fellow will be able to see all new admissions. After morning rounds (around 11:30) the Fellow should check with the other MICU staff and teams to see if there are active issues or procedures to be done on their patients.

Monday-Friday

  • 7:30 - 9:00 p.m.: Pre-round on new admissions and patients with emergent /active issues.
  • 9:00 a.m. - 12:00 p.m. (Noon): See new patients and review old patients during rounds in the ICU.
  • 12:00 p.m. (Noon) - 1:00 p.m.: Departmental Conferences
  • 1:00 - 4:00 p.m.: Help in ICU, eg. Procedures, new patients evaluation,discussion with residents.
  • 4:30 - 5:30 p.m.: Late afternoon MICU rounds, emphasis on likely problems for upcoming night and walk through sign-out with the on-call Fellow.

On-Call
Every 2-3 weekends and about 1-2 weeknights/week. Night call is from home. When Fellows are on call, it is expected that they page the Admitting On-Call Senior Resident around 10:00 pm to discuss new admissions and active problems. The Staff On Call is always available for phone consultation or to come to the hospital to see a patient.

ICU Procedures

  • The MICU staff is always available to supervise any procedure. Staff supervision is required for all bronchoscopies.
  • PF has primary role in bronch, chest tubes, thoracentesis supervision.
  • PF will supervise Swan, A-line, central lines, etc.
  • PF should use MICU Staff as first line resource when problems arise with procedures: eg. difficulty in identifying waveforms during Swan placement or suspected technical problems with pressure monitoring system. (Biomedical and ICU nurses are also helpful resources here).

Intubations
Depending on the individual's level of experience, the PF may have the opportunity to do ICU intubations with either Anesthesia or MICU Staff permission and backup. Before performing intubations in the MICU, the PF should have had significant previous experience with intubation in a non-emergent setting (eg. the OR).

Clinic
Fellows do not attend clinic during their month in the HCMC MICU.

Facilities/Resources
The PF shares an office with the CCFs (Rm # G 5.242) which contains current textbooks on Pulmonary and Critical Care, computers with access to Up To Date and OVID, the computerized medical record (EPIC), and Isite for on-line radiology viewing.

Critical Care Fellow Rotation
Methodist Intensive Care Unit

Objective
The primary goal of the Critical Care rotation is to provide a medical critical care experience in a community-based hospital. The Fellow will care for a variety of patients with critical illness under the direct supervision of the Park Nicollet Pulmonary, Sleep, and Critical Care Medical Staff. Some patients are the primary responsibility of the Fellow and staff; some are cared for on a consultative basis. When co-managing a case, discussion with the Primary Attending will determine the division of responsibility.

Call
The Fellow will be on call for the ICU approximately 10 days during the month. These 10 days will include 2 weekends (Saturday and Sunday). There is staff backup at all times. The staff will field general ward calls, and new ward, ER, or Urgent Care consultations. Ward and outpatient phone calls are sent directly to the Attending On Call. The Fellow is responsible for ICU coverage and will be notified by a Consulting MD or the Attending Staff of a new after-hours consultation. The Fellow should contact the On-Call Staff with any new admissions or if there are any questions regarding current patients.

Intubations
The Fellow is allowed to perform intubations with supervision. Unless emergent, Anesthesia should be present at the initiation of the intubation to function as backup. If emergent, the intubation may be started with Anesthesia en route.

Procedures
Bronchoscopies and chest tubes require the personal attendance of the supervising Pulmonary/ICU MD. The Attending should be aware that the Fellow is placing arterial and central lines but does not need to be in the room unless the Fellow requires assistance (this will depend on the previous experience of the Fellow). A portable ultrasound is available and should be used for all central line placements. Interventional Radiology is also available to assist if needed. Attending staff should be in the ICU and notified when a pulmonary artery catheter is placed.

Mechanical Ventilation
We work closely with Respiratory Therapy. At the beginning of each rotation the Fellow will meet with the head of the Respiratory Therapy Department for orientation to our specific ventilators and weaning protocols. At the initiation of mechanical ventilation, initial ventilator orders and respiratory medications should be entered into Lastword. This is located in the order sets. If the Fellow/Attending makes a ventilatory change they must write it down on the ventilator flow sheet (located on the ventilator)and initial or personally communicate to the ICU Respiratory Therapist. An order directly into Lastword is preferable, but in an emergent situation this can be done with a verbal order to the nurse or therapist. If the ventilator change is not documented, then it is assumed it was made in error and the ventilator will be placed on the previous settings. An incident report may be generated as well.

Infection Control
Obey all isolation signs (VRE, MSRA etc). Wash hands or use the bactericidal rinse located at the door of each room. Use the purple gloves and individual stethoscopes on all patients. If a patient-specific stethoscope is not available, clean your stethoscope with the germicidal cloths (Asepti-Wipe) located on the stand outside of the patient’s room. Utilize full sterile technique for procedures (including mask, gown, and gloves). If in doubt, ask.

Available Protocols

  • Sedation Protocol
  • Weaning Protocol
  • Heparin Protocol
  • Potassium Protocol
  • Ventilator Orders
  • Glucose Protocol

Miscellaneous
Staff is available at all times for case discussion and to assist with patient care.

Regions Hospital

Fellows at Regions spend 2 months in Regions ICUs and 1 month on the Pulmonary Consult Service.

Intensive Care Unit

Intensive Care Unit

The Pulmonary and Critical Care Section provides primary care to all critically ill patients in the MICU and CCU and consultations on patients on other floors for whom consults are requested.  The section also has an outpatient clinic where  both primary patients and consults are seen.

During the two months spent in ICU, the Fellow's primary responsibility will be to the care of all patients in the ICU, including the ICU service.  This may be in either a supervisory or direct patient care role.  When you are on the ICU rotation, you can aid with pulmonary consult procedures (i.e. bronchs or chest tubes) but your primary responsibility is to the ICU patients.  Be aware that the service may have months without a resident on pulmonary consults or limited residents on ICU; the Fellow may be required to cover pulmonary or ICU to alleviate shortages.  Coverage might include admitting patients to the ICU, rounding without residents or possibly changing vacation time.

There are two primary units at Regions that deliver medical ICU care:  the MICU (7 East), a 12-bed medical unit, and CCU (7 South), a 12-bed unit that delivers cardiac-specific and general medical care. The MICU is closed, as the vast majority of patients are on the MICU team; the CCU is open with some medicine, some cardiac and some ICU team patients.  Overflow patients are occasionally followed in SICU (3CM), an 18 bed surgical unit, and Burn Center (5 North), a 2-bed unit. Critical Care acts both as a primary service (majority of patients) and occasionally a consultant service (often for the Regions Hospitalist service).  Admits and bedflow are decided between the Hospitalist and the Intensivists.   There is a Hospitalist of the day who determines admits and bed placement.  We can decline admits; however this is generally not necessary.  We can transfer patients out of the MICU when we deem this is safe.  Because of the Hospitalist, we do not function as the only bed control.

Teams

There are now two Intensive Care teams, each comprised of staff, senior resident, intern and students.  The staff covers both ICU and Pulmonary simultaneously; there is usually a resident on pulmonary consults.  The current master schedule:

  Monday Tuesday Wednesday Thursday Friday Saturday Sunday
ICU B A A A B A A
PulmA A B B B A A A
  Switch       Till 6 pm Both Both

The A and B refer to Attendings on call for new ICU admits and new pulmonary consults, not the resident teams (both Attendings cover pulmonary and critical care services).  Attendings will continue to follow their patients on both services.  Residents/interns will admit patients to the ICU every other day based on their call schedule. There is a resident night float system;  those patients admitted the previous night will roll over to the on-call staff.  The primary resident at Regions does not stay overnight.  Therefore the Fellow on ICU rotations is responsible for all ICU admits, no matter which Attending is on call or which resident is admitting.  The Fellow will, however, round only with the post-call team.  There are times the Fellow will be involved in direct patient care.  During ER conference on Wednesdays we will be short one senior resident.  The Fellow will provide coverage on days the medicine residents have clinic.  Be aware also that residents often have other commitments; it falls to the Fellow to ensure that those days withouth residents run smoothly.  Because of this variable schedule, it is the responsibility of the Fellow to know all patients and to have seen all patients prior to rounds.  Additionally there is an NP, Dottie Hicks, who helps stabilize the “ER Team”.  She is responsible for knowing all non-ICU patients in the ICU and will round and see patient/write notes as a resident or student might.  She will help develop a BIPAP service as well, which will help identify sicker patients prior to their coming to the MICU.

Daily Responsibilities

ICU rounds begin at 8am and generally last until 10am.  There are resident conferences from 9-10 am and 12 noon-1pm.  Rounds override conference attendance; however, depending on the Attending, accommodations will be made.  Besides rounding, the Fellow is responsible for all patients in the ICU, any procedures those patients undergo and procedures we are consulted to perform.  Responsibilities of the Fellow include ventilator/Swan management, pressor/fluid management, eligible transfer assessment, extubation decisions, and education of residents and medical students.  Regions' nurses, social workers, and respiratory therapists are all part of the team and actively participate in rounds.  Fellows have much to learn and much to provide for the team—we ask that you always remember the team approach.

Call/Weekends

The call schedule is determined by each Fellow prior to starting the Regions rotation.  Requirements are 3 weekdays per week and every other weekend.  The call should be balanced evenly among the staff, particularly on weekends.  In a 12-weekend Regions experience, the Fellow can expect to work one weekend with each ICU attending.  Call nights begin at 5pm and will last till 8am.  The Fellow will be the first person called with questions; however staff are always available to help answer questions.  The Fellow is required to do call on both ICU months and the pulmonary month—weekend and nighttime.  If there are any changes in your call schedule, you must notify the Attending, pulmonary secretary/and or operator.