Rotation on the Combined Trauma and Critical Care Service (9 months)

  1. At the conclusion of the rotation, the fellow will be able to demonstrate the appropriate management according to best evidence based practice and evaluate the outcomes of patients with the following conditions. The fellow will acquire sufficient knowledge in the rotation so as to pass the exam for added board certification in surgical critical care at end of his or her training
    • Cardiovascular instability including arrhythmias, myocardial infarction, congestive heart failure, vascular abnormalities, and shock.
    • Respiratory failure including acute respiratory distress syndrome (Acute Lung Injury), chronic obstructive lung disease, respiratory muscle weakness, pneumonia and pulmonary embolus. The fellow will be familiar with the data underlying low tidal volume ventilation and the protocols for management.
    • Renal insufficiency; acute and chronic. Knowledge of the indications and options for dialysis
    • Central nervous system pathology including encephalopathy, cerebral vascular accidents and brain death.
    • Metabolic, endocrine and electrolyte abnormalities.
    • Infectious diseases including sepsis and septic shock, with special consideration for patients who are immunosuppressed. The fellow will be familiar with the guidelines for the treatment of sepsis, based on best available evidence.
    • Hematologic disorders including anemia, neutropenia, thrombocytopenia and thrombocytosis. The fellow will recognize and be able to appropriately manage heparin induced thrombocytopenia, and be familiar with non-heparin anticoagulants. The fellow will also know the latest data on blood transfusions including complications, risks, and transfusion triggers.
    • Gastrointestinal diseases including acute and chronic liver failure, pancreatitis, cholecystitis, gastritis, peptic ulcer disease, and upper and lower gastrointestinal hemorrhage.
    • Obstetric and gynecological disorders, including the management of the critically ill pregnant patient
    • Traumatic injuries, both blunt and penetrating, and the complications peculiar to traumatically injured patients
    • Thermal injuries.
    • Pediatric emergencies
    • Nutritional disorders, and options for nutritional care of patients unable to take adequate nutrition by themselves
    • Oncologic complications.
    • Critical care issues involving the geriatric patient, the morbidly obese patient, and the paralyzed patient.
    • Psychiatric disorders causing special ICU problems, especially the management and latest recommendations for treating agitation and delirium. The fellow will be familiar with sedatives, antipsychotics and anxiolytics. The fellow will also be familiar with various scores for assessing degree of sedation
    • Ethical and legal problems issues in the ICU, including palliative and end of life issues. The fellow will be able to appropriately counsel family members and patients as to outcomes, treatment options and realistic expectations.
  2. At the conclusion of the fellowship, the fellow will be able to demonstrate adequate competence in:
    • Resuscitation skills including advanced cardiopulmonary resuscitation, advanced trauma life support, pediatric life support and crisis management.
    • Airway management using bag and mask ventilation in non-intubated, conscious and unconscious, paralyzed and non-paralyzed patients.
    • Laryngoscopy and intubation.
    • Endoscopy including the performance of percutaneous gastrostomy.
    • Tracheostomy, both percutaneous and open.
    • Ventilator management including the use of volume and pressure modes and the use of supplemental oxygen. The fellow will be expected to implement treatment and adjust ventilator modes to manage elevated airway pressures. The fellow will be familiar with the following salvage modes of ventilating the patient with refractory hypoxemia: prone positioning, high frequency oscillatory ventilation, and bilevel ventilation.
    • Interpretation of pulmonary function tests.
    • Placement of chest thoracostomy tubes.
    • Fiberoptic laryngotracheobronchoscopy for diagnostic and emergency therapeutic interventions.
    • Sterile technique and insertion of arterial, central venous, hemodialysis and pulmonary artery catheters. Many fellows will have already achieved proficiency in these techniques prior to fellowship training, so these fellows will be expected to be able to teach these skills to junior house officers.
    • Interpretation of central venous and pulmonary artery catheter data.
    • Interpretation of electrocardiograms and insertion of emergent transvenous temporary cardiac pacemakers. Pharmacologic support of circulation.
    • Interpretation of arterial blood gas, venous blood gas and other laboratory data.
    • Monitoring and management of patients with central venous system monitors, including intracranial pressure monitoring.
    • Use of pharmacologic agents in the management of ICU patients, including pharmacokinetics, dynamics, metabolism and excretion of these agents.
    • Management of patients with acute allergic reactions and/or anaphylaxis.
    • Management of patients requiring massive fluid and blood product resuscitation. This will include management of the patient who is status post a damage control laparotomy with an open abdomen
    • Application of ethical principles including informed consent, implementation of Do Not Resuscitate Orders, withholding or withdrawing life support and clarifying goals of Advanced Directives, setting treatment goals with patient's surrogate.
    • Pre- and interhospital transportation of critically ill patients.
    • Administrative techniques including gatekeeping, triaging, quality assurance, and policy implementation.
    • Teaching of medical students and residents assigned to the Intensive Care Units.
  3. Evaluate, critique and interpret the critical care literature. Discuss biostatistics and debate experimental design.
  4. Participate in research projects, involving critical care and trauma management and outcomes.
  5. Provide consultation in daily patient care as emergent situations warrant.
  6. Participate in all educational activities including core lecture series, educational workshops, educational modules, Journal Club, Grand Rounds, Research Conferences, and Quality Improvement Conferences. The fellow will be involved in various quality assurance initiatives and will be expected to lead discharge planning rounds
  7. Complete mandatory procedure logbooks verifying primary critical care responsibility of patients sufficient to establish qualifications in surgical critical care.
  8. The fellow shall have a maximum of five patients to which he or she is primarily responsible, but may assist residents in the care of other patients if the needs of the patient or the educational needs of the resident manifest.