Both pulmonary and critical care medicine (PCCM) and critical care medicine (CCM) fellows rotate through the critical care unit (CCU). Fellows rotate under the supervision of the cardiology attending in the CCU. This rotation offers the opportunity for exposure to and management in acute myocardial infarction, advanced heart failure, arrhythmias, inotropic support, and invasive hemodynamic monitoring.
PCCM and CCM fellows will rotate through the CTICU. Both PCCM and CCM fellows are integrated into the rotation and act in the capacity of a CTICU fellow under the supervision of the cardiothoracic anesthesia critical care attendings. This rotation contributes to the multidisciplinary critical care training by providing exposure and experience in the management of extracoporeal life support (including both veno-arterial and veno-venous ECMO), mechanical circulatory support (including ventricular assist devices), post-operative care of thoracic and cardiac surgery patients, as well as post-operative care of lung and heart transplant recipients.
Each PCCM fellow will spend time during the first year of fellowship on the chest radiology service. This rotation is offered as an elective for CCM fellows. The purpose of this rotation is to gain expertise in the interpretation of chest radiographs and thoracic CT scans, understand the indications for and technical considerations in the performance of CT and fluoroscopic guided needle aspiration, and gain familiarity with other diagnostic and therapeutic radiologic procedures utilized in Pulmonary and Critical Care Medicine (pulmonary angiography, bronchial artery embolization, etc.). This is an outstanding opportunity to learn from a superb group of dedicated chest radiologists. PCCM fellows on this service also attend the cystic fibrosis clinic on Monday afternoons.
PCCM fellows on the CF service receive inpatient and outpatient training in the evaluation and management of patients with cystic fibrosis and other bronchiectatic disorders. Training includes performance and interpretation of diagnostic studies, and the acute and chronic management of suppurative lung diseases and its complications, as well as the other systemic complications of cystic fibrosis. Fellows attend the CF outpatient clinic on Monday afternoons.
The objective of this rotation is to give the PCCM fellow experience in the management of patients with end stage lung disease of various etiologies, perioperative and post-operative ICU management of patients undergoing lung transplantation, and in the inpatient and outpatient longitudinal care of patients who are awaiting or who have undergone lung transplantation. The fellow is responsible for inpatient rounds (with the attending) on the transplant service, inpatient and outpatient bronchoscopies and other procedures on the transplant service, and may attend Tuesday afternoon and Wednesday morning Lung Transplant Clinics. Each month, the fellow on the Lung Transplant Service will give a 30 minute presentation on a case or topic related to lung transplantation at the Lung Transplant Conference.
PCCM and CCM fellows rotate through the Medical ICU (MICU). The MICU is a 34 bed ICU located on south campus. The MICU is divided into two services – an 18 bed service and a 16 bed service. Each service has a separate attending, fellow, and house staff service during the day. There is in-house attending and fellow level coverage at night, in addition to the house staff coverage.
The objective of this rotation is to gain expertise in the medical management of critically ill patients including but not limited to ventilator management, use of vasoactive agents, and to gain expertise in the performance and interpretation of invasive and noninvasive hemodynamic monitoring procedures. There is the opportunity for procedures such as intubations, arterial and venous line placements, and chest tubes.
Fellows will lead work rounds when plans for the day are formulated and procedures are planned. The attending will supervise and provide additional assistance and guidance in directing patient care.
PCCM and CCM fellows will rotate through the NNICU. Both PCCM and CCM fellows are integrated into this rotation and act as a NNICU fellow under the supervision of the neurologic critical care attendings. This rotation contributes to multidisciplinary training in critical care medicine by allowing exposure to and experience in managing acute strokes, intracranial hemorrhage, elevated intracranial pressure, and post-operative care of neurosurgical patients.
The PPCU is a 9 bed ventilator weaning and rehabilitation floor. The PCCM fellow and attendings assigned to the consult service provide consultative services to the PPCU hospitalist regarding chronic ventilator weaning and tracheostomy management. This rotation provides the opportunity for fellows to learn more about chronic ventilator management and weaning, use of long term non-invasive ventilation, and management of tracheostomies including changing tracheostomy tubes and criteria for decannulation. In addition, the fellow has an opportunity to work with an experienced multi-disciplinary team comprised of hospitalists, nurse practitioners, respiratory therapists, and physical therapists in helping the patients of this unit attain improved functional status. This rotation is offered as an elective for CCM fellows.
The general Pulmonary Consult Service provides pulmonary consultation throughout the hospital in the inpatient setting (South Campus), non-medical intensive care units, and the Emergency Room. One PCCM fellow is always assigned to this service and supervises the activities of the medical residents and students rotating through pulmonary as an integral part of the consult team. The consult service performs the bronchoscopies required by patients seen on the consult service.
A vast array of patients with multiple underlying disorders including airway diseases, interstitial diseases, respiratory infections, pulmonary vascular disease, pleural disease, neuromuscular disease, respiratory failure and critical illness, and pulmonary complications of solid organ transplantation is encountered.
PCCM fellows on this rotation will review, interpret, and supervise pulmonary function testing under the supervision of a pulmonary attending. Testing performed includes spirometry, lung volumes, diffusing capacity, oxygen assessments, methacholine challenges, and cardiopulmonary exercise tests. In addition, fellows will spend a half day on the pulmonary rehabilitation service to better understand the indications for and components of a pulmonary rehabilitation program.
PCCM fellows on the PH service receive inpatient and outpatient training in the evaluation and management of patients with primary and secondary causes of pulmonary hypertension. Training includes performance and interpretation of diagnostic studies, and the acute and chronic management of complex vasodilator therapies including chronic vasodilator infusions. Fellows also attend the pulmonary vascular disease clinic on Tuesdays and Thursdays.
PCCM fellows on the sleep medicine service rotate through the Washington University Multidisciplinary Sleep Medicine Clinic which is located approximately 5 miles away from Barnes-Jewish Hospital. Fellows rotating through this service have the opportunity to see patients with sleep disordered breathing, restless leg syndrome, narcolepsy, as well as a variety of other sleep disorders. Fellows can become familiarized with reviewing polysomnograms. Fellows work with attendings within pulmonary, neurology, and psychiatry on this rotation.
PCCM and CCM fellows will rotate through the Stem Cell Transplant/Oncology ICU. Fellows are responsible for leading rounds with the pulmonary/critical care medicine attending and the nurse practitioners. In addition, fellows supervise and perform needed procedures, as well as lead family discussions. Interdisciplinary rounds are held on a daily basis with the stem cell transplant (SCT) and oncology services. Fellows will also see pulmonary consults requested on SCT and oncology patients not in the ICU on the North Campus. If bronchoscopies are required on these consult patients, they are performed by the fellow and SCT/Oncology ICU attending.
This rotation allows for multidisciplinary training by exposing fellows to the management of patients with newly diagnosed hematologic malignancies, as well as the complications associated with the treatment and management of oncology patients and post stem cell transplant patients.
PCCM and CCM fellows will rotate through the SICU. Both PCCM and CCM fellows are integrated into the rotation and act in the capacity of a SICU fellow during this rotation under the supervision of the surgical and anesthesia critical care attendings. This rotation allows for broad multidisciplinary training in critical care medicine by providing exposure to critical care management in trauma and post-operative patients.
PCCM fellows rotate through the John Cochran VA during their first year. The VA medical center (VAMC) is located less than three miles away from the primary teaching hospital, Barnes-Jewish Hospital (BJH). Fellows at the VA round in the MICU with the critical care attending and ICU hospitalist team. During this rotation, fellows also spend time with the pulmonary consultation service at the VAMC, which provides exposure to inpatient and outpatient consultations, pulmonary function testing and pulmonary rehabilitation.