Clinical Training

Nine months of the 12-month fellowship period are reserved for ICU training. Fellows divide their clinical training months among several intensive care units, including the 24-bed Surgery/Burn/Trauma Intensive Care Unit (SICU), Cardiothoracic ICU, Neurology and Neurosurgery ICU, Medical ICU, Coronary Care Unit and Pediatric ICU..

Typically, fellows perform about half of their clinical training in the SICU; the remaining rotations are chosen to satisfy Accreditation Council for Graduate Medical Education (ACGME) program requirements while also meeting fellows' individual interests. Additional rotations are available in airway/anesthesiology, trauma surgery, pulmonary medicine, renal medicine, infectious diseases, nutrition support, radiology and cardiac echography.

Fellows primarily interested in pediatrics may tailor their fellowship experiences to emphasize pediatric critical care.

Clinical Training Environment

Washington University Medical Center offers an ideal environment for clinical training. The School of Medicine is consistently ranked among the top medical schools in the United States, and the Medical Center is an acknowledged leader in critical care services. The Medical Center also is the region's largest health care provider and its referral base extends into several neighboring states. As a result, critical care fellows are exposed to a large and diverse patient population, including a substantial number of very complicated cases.

Fellows benefit from the expertise of outstanding critical care faculty, and they perform their medical duties in facilities that are among the most advanced in the country. Critical care units are equipped with leading-edge technology and are designed to accommodate innovative treatment approaches. Washington University is known for its highly collaborative and interdisciplinary approach to patient care. This atmosphere enriches the training experience by exposing fellows to the many facets of medicine.

Clinical Fellow Training Opportunities

Surgery/Burn/Trauma Intensive Care Unit (SICU): This 24-bed unit is an advanced facility that was completed in January 1997 and receives more than 1,600 admissions each year. It is the primary training base for surgical critical care fellows. The unit serves general surgical patients and patients from all the surgical specialties except cardiothoracic surgery and neurosurgery. Because Washington University Medical Center is a Level 1 trauma center and a regional burn center, the unit serves many trauma and burn patients. Fellows also treat patients who have had vascular, transplant, hepatobiliary, endocrine/oncology, ON/GYN, urological, ENT and orthopedic surgical procedures. Fellows participate in the care of all SICU patients.

Cardiothoracic Intensive Care Unit: Fellows assist in the management of the complex pathophysiology associated with cases in this 21-bed unit, which serves all cardiac and thoracic surgical patients at Barnes-Jewish Hospital. In addition to a large general cardiac and thoracic caseload, Washington University has the world's largest lung transplantation program and an active cardiac transplantation program.

Neurology and Neurosurgery Intensive Care Unit: This 20-bed unit serves more than 1,000 patients a year. Fellows learn to manage a wide variety of primary brain and spinal cord insults.

Medical Intensive Care Unit: This 19-bed unit is the primary intensive care unit for critically ill patients from all medical subspecialties except cardiology. Fellows are directly involved in the management of all patients and have ample opportunity to learn diagnostic procedures and therapeutic interventions.

Coronary Care Unit: This 15-bed unit is the primary intensive care unit for critically ill patients with acute myocardial disease. Fellows gain extensive exposure to noninvasive diagnostic techniques and interventional cardiology.

Pediatric Intensive Care Unit: This 22-bed unit encompasses a wide range of cardiac and non-cardiac congenital and acquired pathophysiology cases in the pediatric population. Fellows study the pathophysiology of medical and surgical critical illness in infants and children; learn diagnostic skills and therapeutic procedures; and participate in rounds, didactic presentations, on-call status and teaching of residents and medical students.

Clinical Simulation Center: This center features a lifelike, computerized mannequin that can be programmed to simulate a live patient's response to scores of clinical situations. It provides hands-on training in critical care, surgical anesthesia, emergency care and advanced cardiac life support.

Clinical Training Educational Objectives

Formal goals of core and elective rotations for the Surgical Critical Care Fellowship Program at Washington University School of Medicine/Barnes-Jewish Hospital are:

1) Surgical ICU (84ICU) — Upon completion of the multiple rotations the fellow will spend in this ICU, it is expected the fellow will have exposure to and develop clinical expertise in: airway maintenance and management, mechanical ventilation and devices that supply supplemental oxygen, indications of and techniques for emergency and therapeutic treatment of conditions requiring thoracentesis and/or tube thoracotomy, emergency and therapeutic fiberoptic laryngotracheobronchoscopy, assessment and evaluation of pulmonary function, cardiopulmonary resuscitation, placement and management of arterial, central venous and pulmonary arterial catheters, computations of cardiac output and of systemic and pulmonary vascular resistance, monitoring electrocardiograms, pharmacologic and mechanical support of circulation, evaluation of central nervous system dysfunction, use of intracranial pressure monitoring techniques, recognition and treatment of hepatic and renal dysfunction, knowledge of the indications and complications of hemodialysis, diagnosis and treatment of sepsis, fluid resuscitation and management of massive blood loss, enteral and total parenteral nutrition, utilization of gastrointestinal intubation and endoscopic techniques in the management of the critically ill patient, management of stomas, fistulas and percutaneous catheter devices, application of autotransfusion, assessment of coagulation status, appropriate use of component therapy, bioengineering and monitoring including use and calibration of transducers, amplifiers and recorders, interpretation of relevant laboratory results, psychiatric effects of critical illness, ethical and legal aspects of critical care, critical obstetric and gynecologic disorders, trauma, thermal, electrical and radiation injuries, inhalation and immersion injuries, pharmacokinetics and dynamics of drug metabolism and excretion in critical illness, classification of infections and application of isolation techniques, drug interactions and management of antibiotic therapy during organ failure, nosocomial infections, principles and techniques of administration and management, use of special beds for specific injuries, traction, and fixation devices, and biostatistics and experimental design.

2) Cardiothoracic ICU (56ICU) — Upon completion of this rotation, it is expected the fellow will have exposure to and develop clinical expertise in indications of and techniques for emergency and therapeutic treatment of conditions requiring thoracentesis and/or tube thoracotomy, cardiopulmonary resuscitation, central venous and pulmonary arterial catheters, emergency and therapeutic placement of pacemakers, computations of cardiac output and of systemic and pulmonary vascular resistance, monitoring electrocardiograms, management of cardiac assist devices, pharmacologic and mechanical support of circulation, fluid resuscitation and management of massive blood loss, bioengineering and monitoring, interpretation of relevant laboratory results, and transesophageal echocardiography (TEE).

3) Medical ICU (83ICU) — Upon completion of this rotation, it is expected the fellow will have exposure to and develop clinical expertise in mechanical ventilation and devices that supply supplemental oxygen, assessment and evaluation of pulmonary function, cardiopulmonary resuscitation, pharmacologic and mechanical support of circulation, recognition and treatment of hepatic and dysfunction, diagnosis and treatment of sepsis, bioengineering and monitoring, interpretation of relevant laboratory results, assessment of coagulation status, and appropriate use of component therapy.

4) Coronary Care Unit (82ICU) — Upon completion of this rotation, it is expected the fellow will have exposure to and develop clinical expertise in cardiopulmonary resuscitation, central venous and pulmonary arterial catheters, emergency and therapeutic placement of pacemakers, pharmacologic and mechanical support of circulation, interpretation of relevant laboratory results, transesophageal echocardiography (TEE), computations of cardiac output and of systemic and pulmonary vascular resistance, and monitoring electrocardiograms.

5) Pediatric ICU — Upon completion of this rotation, it is expected the fellow will have exposure to and develop clinical expertise in critical pediatric surgical conditions, pharmacologic and mechanical support of circulation, and interpretation of relevant laboratory results.

6) Neurologic/Neurosurgery ICU (104ICU) — Upon completion of this rotation, it is expected the fellow will have exposure to and develop clinical expertise in evaluation of central nervous system dysfunction, the performance of complete neurologic examinations, use of intracranial pressure monitoring techniques and of the electroencephalogram to evaluate cerebral function, and interpretation of relevant laboratory results.

7) Infectious Diseases Consult — Upon completion of this rotation, it is expected the fellow will have exposure to and develop clinical expertise in interpretation of relevant laboratory and microbiological results, classification of infections and application of isolation techniques, drug interactions, and management of antibiotic therapy in nosocomial infections.

8) Renal Consult — Upon completion of this rotation, it is expected the fellow will have exposure to and develop clinical expertise in recognition and treatment of renal dysfunction, knowledge of the indications and complications of hemodialysis (both intermittent and continuous) as well as ultrafiltration, and interpretation of relevant laboratory results.

9) Pulmonary Consult — Upon completion of this rotation, it is expected the fellow will have exposure to and develop clinical expertise in devices that supply supplemental oxygen, emergency and therapeutic fiberoptic laryngotracheobronchoscopy, and assessment and evaluation of pulmonary function.

10) Airway/Anesthesiology — Upon completion of this rotation, it is expected the fellow will have exposure to and develop clinical expertise in airway maintenance and management, emergency and therapeutic fiberoptic laryngotracheobronchoscopy.

11) Trauma Surgery — Upon completion of this rotation, it is expected the fellow will have exposure to and develop clinical expertise in the operative and medical management of patients with trauma, thermal electrical, inhalation and immersion injuries, indications of and techniques for emergency and therapeutic treatment of conditions requiring thoracentesis and/or tube thoracotomy, fluid resuscitation and management of massive blood loss.

12) Research — Upon completion of this rotation, it is expected the fellow will have exposure to and develop expertise in biostatistics and experimental design and interpretation of relevant laboratory results.

13) Transesophageal echo (TEE) — Upon completion of this rotation, it is expected the fellow will have exposure to and develop expertise in transesophageal echo. This includes computation of cardiac output and of pulmonary vascular resistance and determination of valvular and wall abnormalities.

14) Radiology — Upon completion of this rotation, it is expected the fellow will have exposure to and develop expertise in interpretation of computed tomography (CT) scans and chest radiographs. This should include analyzing a wide range of radiographic images, from normal studies to those with severe pathology commonly present in critically ill patients.

15) Nutrition — Upon completion of this rotation, it is expected the fellow will have exposure to and develop clinical expertise in enteral and parenteral nutrition formulas, placing bedside feeding tubes, fluid and electrolyte management and writing TPN orders.