Pulmonary Critical Care Clinical Training

Advisors: Rana Hejal, MD and Shine Raju, MD

Rotation Description:

The MICU at UHCMC is a closed unit with 20 ICU beds and 6 step down unit beds. To better balance teaching with patient care service, the MICU is split into two teams, each including an attending, fellow, and residents. The fellows make daily work/ teaching rounds and take turns with the attending to give daily didactic sessions for the house staff. The attending and fellow also provide consultations on patients admitted to other critical care units. Fellows receive experience with:

• Adjuvant therapy for respiratory failure (prone positioning, NO, etc.)
• Management of multisystem failure
• Management of end-stage solid organ transplant candidates
• Dialytic therapy
• Multidisciplinary patient management
• Medical ethics and end-of-life issues
• Unit organization, patient safety, and clinical management protocols

Daily Activities and Responsibilities:

Two daytime fellows and one nighttime fellow will staff UHMICU 24 hours a day. All fellows on UH MICU will be exempt of their continuity clinic duties.

Daytime fellows:

Days of work: The daytime fellows will have one weekend day off on average during their rotation. (Days off are decided among the fellows themselves. In case of disagreement, the chief fellows will make the final decision)

Hours of work: 7:00 am - 7:00 pm
The two daytime fellows will be present at 7:00 am to receive "sign out" from the nighttime fellow.
The two daytime fellows will be present at 7:00 pm to give "sign out" to the nighttime fellow. On rare instances (scheduled medical appointments, emergencies…) it is acceptable for one of the daytime fellows to give "sign out" to the daytime fellow who will discuss it with the nighttime fellow.

Conference attendance: Daytime fellows are expected to attend all mandatory conferences. In case of the emergencies in the ICU fellows who won't be at conference will have to alert the chief fellows.

Daily activities:

• Rounds start promptly at 8:30 am.
• Daytime fellows will admit new patients to the MICU on alternate days.
• Daytime fellows will lead rounds under the supervision of the attending.
• Daytime fellows will be available to answer residents, nursing and respiratory therapy questions.
• Daytime fellows will assist with procedures and establishing airway.
• They will document these procedures in the EMR.
• Daytime fellow on call will assist the rapid response team as needed.

Nighttime fellow:

Days of work:  The nighttime fellow works Sunday to Thursday. Friday and Saturday are covered by a different fellow who will assume the same responsibilities.

Hours of work: 7:00 pm - 7:00 am
The nighttime fellow will be present at 7:00 pm to receive "sign out" from the daytime fellows.
The nighttime fellow will be present at 7:00 am to give "sign out" to the daytime fellows.

Conference attendance: The nighttime fellow is expected to attend all mandatory conferences.

Daily activities:

• The nighttime fellow will discuss all existing patients with on call residents and interns. They will evaluate any patient as clinically necessary.
• The nighttime fellow will evaluate every new admission and alert the attending physician.
• The nighttime fellow will be available to answer residents, nursing and respiratory therapy questions.
• The nighttime fellow will assist with procedures and establishing airway, and document these procedures in the EMR.
• Daytime fellow on call will assist the rapid response team as needed Will divide the nighttime admission between the two MICU day teams.
• Will assess readiness for extubation on all patients and alert the beside nurse to hold sedation and with the respiratory therapist.

Advisors:  Rodney Folz, MD and Catalina Teba, MD

Rotation Description:

The UH Pulmonary Consultation Service team consists of a faculty attending, one fellow, residents, and students on elective rotations. Approximately 900 consultations are requested yearly. The consult team is also responsible for the care of inpatients who are on the Pulmonary Service/Flex service. Fellows learn the latest diagnostic and management approach to common and rare diseases, including:

• Interstitial lung diseases
• Obstructive lung diseases
• Lung cancer
• Infectious diseases of the lung
• Diseases of the immunocompromised host
• Vascular disease

Daily Activities and Responsibilities:

One fellow and will be assigned to cover UH pulmonary consultation service. On UH pulmonary consultation service the fellow will continue to have his/her continuity clinics.

Days of work: The fellow will work Monday to Friday

Hours of work: The fellows’ responsibilities start at 8:00 am or following conference/Grand Rounds. The fellow will be physically present till 5:00 pm.

Conference attendance: Daytime fellows are expected to attend all mandatory conferences.

Daily activities:

• Rounding time will be discussed with the attending at the start of the rotation and can vary slightly depending on workflow, new consults, clinics and scheduled procedures.
• Consult called before 5:00 pm will be seen on the same day.
• Urgent consults have to be seen within 4 hours.
• Non-urgent consults called after 5:00 pm can be seen the following morning.
• The fellow will lead rounds under the supervision of the attending.
• The consult fellow will work closely with the procedure fellow on distribution of inpatient procedures
• The consult fellow will utilize the add-on bronchoscopy list for inpatient procedure. This document is then circulated to the procedure fellow, procedure attending and bronchoscopy staff.

Rotation Description:

The UH Pulmonary Procedure Service team consists of a faculty attending and one fellow. Approximately 700 total bronchoscopies are done yearly with about 250 endobronchial ultrasound (EBUS), 100 electromagnetic navigation (EMN), 150 therapeutic bronchoscopies, 25 rigid bronchoscopies and 30 stent placements. Other procedures include bronchial thermoplasty, transbronchial cryobiopsy, photodynamic therapy, bronchography and endobronchial valve placement.

Daily Activities and Responsibilities:

One fellow will be assigned to cover UH pulmonary procedure service. On UH pulmonary procedure service the fellow will continue to have his/her continuity clinics.

Days of work: The fellow will work Monday to Friday.

Hours of work: The fellow’s responsibilities start at 8:00 am or following conference/Grand Rounds. The fellow will be physically present until all procedures are completed and documented for that day, and all of the patients have left the procedural suite.

Conference attendance: Daytime fellows are expected to attend all mandatory conferences.

Daily activities:

• The procedure fellow will evaluate all schedule outpatient procedures (review pertinent history, labs, and imaging).
• The procedure fellow will obtain consent.
• The procedure will document the procedures on the day it is completed.
• The fellow will work under direct supervision of the attending.
• The consult fellow will work closely with the procedure fellow on distribution of inpatient procedures.

Advisors: Rodney Folz, MD and Maroun Matta, MD

Rotation Description:

In addition to their continuity clinic, fellows on the ambulatory rotation will assist in a wide array of subspecialty clinics including cystic fibrosis, primary ciliary dyskinesia, sleep, pulmonary hypertension, allergy and immunology, lung transplant, and interstitial lung diseases. Fellows will participate and experience a pulmonary function test and a cardiopulmonary exercise test. Fellows on the ambulatory rotation will also visit our pulmonary rehab facility.

Daily Activities and Responsibilities:

One fellow will be assigned to cover UH ambulatory procedure service. On UH ambulatory procedure service, the fellow will have 2 half day continuity clinics per week.

Days of work: The fellow will work Monday to Friday.

Hours of work: The fellow’s responsibilities start at 8:00 am or following conference/Grand Rounds. 

Conference attendance: Daytime fellows are expected to attend all mandatory conferences.

Daily activities:

• The fellow will have 2 half day continuity clinics per week.
• The fellow will attend and participate in the scheduled clinics (CF, PCD, allergy/immunology, sleep, lung nodule clinic). The chief fellows or fellowship director will distribute this schedule to the fellows.
• The ambulatory fellow will read PFTs for UH.

Advisors:  Maroun Matta, MD and Robert Schilz, MD

Rotation Description:

The fellow on Advanced Lung Disease manages in-patient service of patients with pulmonary hypertension or lung transplants. Fellows participate in the pre-transplant evaluation, peri-operative care, and post-transplant management. The Division also cares for a large patient population with pulmonary hypertension on IV infusion therapy.

• Transplant evaluation, indications, pre-operative management
• Work-up and treatment of pulmonary hypertension
• Immunosuppressive therapy
• Management of acute and chronic rejection
• Management of right heart failure

Daily Activities and Responsibilities:

The fellow on advanced lung disease will continue to have his/her continuity clinic, and are expected to attend all mandatory conferences.

Outside of the PCCM obligations above, the fellow on advanced lung diseases will round on inpatient transplant patients with the transplant team, attend the transplant committee meeting on Thursday morning (7:15 am - 8:00 am) and ILD MDD on Wednesday (3:00 pm - 4:00 pm). Unless overlaps with inpatient duty or continuity clinics the fellows can attend the following clinics:

• Lung transplant clinic, Tuesday afternoon: Schilz
• Lung transplant clinic, Friday morning: Matta
• PHTN clinic, Monday and Thursday: Schilz
• ILD clinic, Friday afternoon: Matta

Advisors: Kim McBennett, MD and Olivia Giddings, MD, PhD

Rotation Description:

UH Rainbow Babies & Children’s Hospital is home to one of the largest cystic fibrosis centers in Ohio and one of the first Cystic Fibrosis Foundation accredited care centers in the nation. During this rotation the fellow will:

• Understand how the diagnosis of cystic fibrosis (CF) in adults is made and how to diagnose CF with acute exacerbation
• Become familiar with the pulmonary (hemoptysis, pneumothorax, etc.) and extra-pulmonary manifestations of CF
• Learn the new treatments in CF, including CFTR modulators, and how they are prescribed to patients

Daily Activities and Responsibilities:

The fellow on CF will continue to have his/her continuity clinic, and are expected to attend all mandatory conferences (Monday noon, Wednesday and Thursday morning, Friday morning, Friday noon).

Outside of the PCCM obligations above, the fellow on CF will work as an integral part of the CF team, attending:

• Outpatient clinic 1/2 day per week (either Wednesday morning or afternoon) when available
• Rounds with the CF team on the adult inpatient service
• Will attend interdisciplinary team rounds on Monday and Thursday at 10:00 am

Advisors: Anna May, MD and Ambrose Chiang, MD

Rotation Description:

During this rotation fellows will work closely with our sleep medicine specialist. Fellow will familiarize with:

• Sleep-disordered breathing (OSA, CSA, Cheyne-stokes breathing)
• Non-respiratory sleep disorders
  • narcolepsy
  • circadian rhythm disorders
  • insufficient sleep
  • insomnia
  • parasomnias
• Interaction of sleep with other chronic medical disease such as chronic lung disease, cardiac disease and depression
• Restless leg syndrome

Daily Activities and Responsibilities:

The fellow on sleep clinic will continue to have his/her continuity clinic, and are expected to attend all mandatory conferences.

Outside of the PCCM obligations above, the fellow on sleep rotation will discuss with Dr. May the dates and locations of sleep clinics he/she can assist with. He/she will also assist with fellows sleep clinic at the VA.

During their fellowship training, fellows are required to complete 3 months of non-medical ICU including surgical, neurological, trauma and cardiothoracic ICU.

The fellow on non-medical ICU will work as an integral part of the non-medical ICU team, assisting with rounds, admissions, follow ups and didactics.

Detailed objectives are available in the fellowship manual.

Advisors: Frank Jacono, MD and Mohammad Shatat, MD

Rotation Description:

The MICU at the VA is a closed unit with 16 ICU beds shared with cardiology. The VA MICU has approximately 600 admits/year. The MICU team has one attending, one fellow, residents, and subinterns. The fellow leads daily work/ teaching rounds and takes turns with the attending to give daily didactic sessions for the house staff. Fellows receive experience with:

• Management of multisystem failure
• Adjuvant therapy for respiratory failure (prone positioning, NO, etc.)
• Dialytic therapy
• Multidisciplinary patient management
• Medical ethics and end-of-life issues
• Unit organization, patient safety, and clinical management protocols

Daily Activities and Responsibilities:

One fellow and will be assigned to cover VA MICU. On VA MICU, the fellow will continue to have his/her continuity clinics.

Days of work: The fellow will work Monday to Friday.

Hours of work: The fellow's responsibilities start at 8:00 am or following conference/Grand Rounds. The fellow will be present at the VA till 5:00 pm.

Conference attendance: Daytime fellows are expected to attend all mandatory conferences. In case of the emergencies in the ICU, fellows who won't be at conference will have to alert the chief fellows.

Daily activities:

• Rounds start promptly at 8:30 am.
• The fellow will evaluate every new admission to the MICU between 8:00 am - 5:00 pm.
• The fellow will be available overnight to discuss with the resident new admissions and change of status in existing patients and will alert the attending physician.
• The fellow will lead rounds under the supervision of the attending.
• The fellow will be available to answer residents, nursing and respiratory therapy questions.
• The fellow will assist with procedures and establishing airway, and document these procedures in the EMR.

Advisors: Frank Jacono, MD and Joanne Mckell, MD

Rotation Description:

The VA Pulmonary Consultation Service team consists of a faculty attending, one fellow, residents, and students on elective rotations. Approximately 500 consultations are requested yearly. Fellows learn the latest diagnostic and management approach to common and rare diseases, including:

• Interstitial lung diseases
• Obstructive lung diseases
• Lung cancer
• Infectious diseases of the lung
• Diseases of the immunocompromised host
• Vascular disease

Daily Activities and Responsibilities:

One fellow will be assigned to cover VA pulmonary procedure service. On VA pulmonary consultation service, the fellow will have 3 half day clinics.

Days of work: The fellow will work Monday to Friday.

Hours of work: The fellow’s responsibilities start at 8:00 am or following conference/Grand Rounds. The fellow will be physically present till 5:00 pm.

Conference attendance: Daytime fellows are expected to attend all mandatory conferences.

Daily activities:

• Consult fellow will have pulmonary clinic Monday to Thursday from 8:00 am - 12:00 pm.
• Rounding time will be discussed with the attending at the start of the rotation and can vary slightly depending on workflow, new consults, clinics and scheduled procedures.
• Consult called before 5:00 pm will be seen on the same day.
• Urgent consults have to be seen within 4 hours.
• Non-urgent consults called after 5:00 pm can be seen the following morning.
• The fellow will lead rounds under the supervision of the attending.
• The consult fellow will work closely with the procedure fellow on distribution of inpatient procedures.
• The consult fellow will read PFTs for the VA and review them with the consult attending.

Advisors: Mohammad Shatat, MD

Rotation Description:

The VA Pulmonary Procedure Service team consists of a faculty attending and one fellow. Approximately 300 total bronchoscopies are done yearly with about 150 endobronchial ultrasound (EBUS), 30 endobronchial magnetic navigation (EMN).

Daily Activities and Responsibilities:

One fellow will be assigned to cover VA pulmonary procedure service.  On VA pulmonary procedure service, the fellow will have 2 half day clinics (Monday and Thursday).

Days of work: The fellow will work Monday to Friday.

Hours of work: The fellow’s responsibilities start at 8:00 am or following conference/Grand Rounds. The fellow will be physically present until all procedures are completed and documented for that day.

Conference attendance: Daytime fellows are expected to attend all mandatory conferences.

Daily activities:

• The procedure fellow will evaluate all schedule outpatient procedures (review pertinent hx, labs, and imaging).
• The procedure fellow will obtain consent.
• The procedure will document the procedures on the day it is completed.
• The fellow will work under direct supervision of the attending.
• The consult fellow will work closely with the procedure fellow on distribution of inpatient procedures.
• The procedure fellow will follow up on pathology results from procedure and sign out any pending results to the incoming procedure fellow at the end of the rotation.