The Medical Intensive Care Unit Service is four months and consists of the Pulmonary/Critical Care Attending, first year fellow, three teams of two house officers each, and a fourth year Tufts University medical student. This is a closed ICU service covering the 10 bed Medical Intensive Care Unit (MICU) and medical patients admitted to the adjacent Intensive Care Units when there is overflow.
This rotation provides the fellow with broad experience in medical and neurological critical care. Emphasis is placed on the pathophysiologic basis, diagnosis and management of a broad range of diseases seen in the MICU. Additional education goals include developing technical expertise in critical care bronchoscopy, central line and pulmonary arterial catheter placement, clinical applications of ultrasonography, interpretation of hemodynamic information obtained from pulmonary artery catheters, endotracheal intubation and the application of invasive and non-invasive mechanical ventilation. The fellow will also have the opportunity to teach medical residents and medical students in the MICU setting.
Intensive care unit work rounds are conducted each morning, supervised by the MICU attending and fellow. The focus is on patient care and bedside teaching. Special emphasis is placed on teaching the principles of mechanical ventilation, respiratory and hemodynamic monitoring and critical care decision making. Afternoon rounds are conducted by the MICU fellow and provide an opportunity for the fellow to have a direct supervisory role in the MICU setting.
The case mix in the MICU service provides a broad educational exposure for the first year fellow with extensive experience gained in the management of patients with acute respiratory failure from COPD, asthma, pneumonia, pulmonary hemorrhage, neuromuscular disease and opportunistic lung infection, acute lung injury/ARDS (including application of nitric oxide therapy, prone positioning, lung protective mechanical ventilation strategy), drug overdose, sepsis/septic shock, gastrointestinal bleeding, acute and chronic hepatic failure, diabetic ketoacidosis, acute renal failure and pulmonary hypertension.
The fellow also has the opportunity to participate in a number of ongoing studies in the MICU on various aspects of mechanical ventilation including the application of non-invasive ventilation to improve weaning and extubation outcome, investigation of weaning and extubation predictors and longitudinal epidemiology studies of the outcome of mechanical ventilation. There is also active research in ARDS, the use of sedation and analgesia, end of life decision making and neuroprotective therapy in stroke.
The Inpatient Consult Service lasts three months and consists of a consult attending, consult fellow and one fourth year medical student. Consult rounds are made daily and consist of a review of previously evaluated cases and detailed discussion of new consults. Extensive time is committed to reviewing all radiographic studies (plain radiograph, computerized tomography, nuclear medicine), pathological specimens and pulmonary function test data obtained on patients evaluated by the consult service.
The multitude of reasons for pulmonary consultation provides a broad substrate for educating the first-year fellow. Reasons for consultation include preoperative pulmonary assessment, diagnosis and management of unexplained dyspnea, hypercapnia or hypoxemia, infiltrates in immunocompromised hosts, interstitial lung disease, hemoptysis, pulmonary hypertension, lung masses, pleural diseases, pulmonary embolism, sleep apnea, and difficult to manage COPD and asthma. Consults originate from medical specialty wards including infectious diseases, gastroenterology, nephrology, hematology, bone marrow transplant, oncology, cardiology and general medicine, and from non-medical specialties such as cardiothoracic surgery, orthopedics and obstetrics and gynecology.
The fellow plays a central role in the education of the house staff who request these consultations. In addition, there is ample opportunity to learn from other specialists who often are asked to consult on these complex cases. The fellow obtains significant experience with fiberoptic bronchoscopy, bronchoalveolar lavage and transbronchial biopsy.
During this rotation, the fellow performs consultations on patients in the Coronary Care Unit, Cardiothoracic Unit and Surgical ICU, and rounds on those patients with the staff. The focus of these consultations is often the management of patients with acute lung injury and weaning from mechanical ventilators. The consult service is also responsible for performing consults at the New England Sinai/Boston that provides exposure to subacute and chronic care patients requiring mechanical ventilation and patients undergoing pulmonary rehabilitation. The consult fellow is responsible for reading the pulmonary function tests and the cardiopulmonary exercise tests on a daily basis with the with the consult attending.
Lowell Intensive Care Unit Service: (two months)
First year fellows rotate through the consult service at Lowell General Hospital for two months. The case mix in this setting provides an excellent complement to the tertiary care setting of Tufts Medical Center by offering extensive exposure to an underserved patient population with a wide range of pathology.
This rotation also incorporates an airway experience in the OR at Lowell General with an emphasis on learning the basic techniques of endotracheal intubation. Finally, the fellows on this rotation also get exposure to advanced bronchoscopy/EBUS twice a week as part of the Thoracic Oncology program at Lowell General Hospital.
