Curriculum

After completing training, fellows are expected to

Diagnose and manage the following conditions:

• Obstructive lung disease
• Pulmonary malignancies, including primary and metastatic cancers
• Pulmonary infections due to all causes
• Pulmonary infections that occur in the immunocompromised host
• Diffuse interstitial diseases
• Pulmonary vascular diseases such as pulmonary vasculitis, pulmonary hemorrhage, pulmonary embolism, and pulmonary hypertension
• Occupational lung disorders
• Diseases due to drugs and radiation therapy
• Pulmonary diseases associated with connective tissue disorders
• Pleural space problems due to infection, neoplasms, and pneumothorax
• Inherited pulmonary diseases such as alpha-1 antitrypsin deficiency and cystic fibrosis.
• Know the indications for and management of lung transplantation.
• Interpret chest x-rays, chest computed tomography, ventilation perfusion scans, and pulmonary angiograms.
• Assess pre-operative pulmonary risk.
• Assess disability related to pulmonary diseases.
• Understand the pharmacology of drugs commonly used in patients with pulmonary diseases.
• Manage chest wall deformities.
• Manage neurological and muscular disorders affecting ventilation.
   

After completing training, fellows are expected to

 Diagnose and manage acute respiratory failure due to all causes.

• Manage ventilators and know the proper use of different ventilator modalities.
• Know the indications for and proper use of non-invasive ventilator modalities.
• Wean patients from mechanical ventilation.
• Diagnose and manage sepsis.
• Know the proper management of airway in intubated and non-intubated patients.
• Intubate with a laryngoscope and with a bronchoscope.
• Manage enteral and parenteral nutrition.
• Measure and interpret arterial blood gases 
• Measure and interpret hemodynamic studies.
• Manage sedation for intubated patients.
• Know the proper use of paralytic agents.
• Measure and interpret outcomes in the medical intensive care unit.
• Manage renal and electrolyte problems in critically ill patients.
• Know the proper management of blood transfusions and transfusion reactions.
• Know the proper management of hemostatic disorders.
• Manage anaphylaxis and acute allergic reactions.
• Manage postoperative patients and complications.
• Diagnose and manage nosocomial pneumonia.
• Assess and manage psychosocial and emotional issues of critically ill individuals and their families.
• Understand clinical, economic, and legal aspects of the care of critically ill patients.
• Understand obstetric and gynecologic disorders.
• Understand the pharmacology of drugs commonly used in critically ill patients.
• Manage chest trauma.
• Manage drug overdose.
• Diagnose and manage gastrointestinal hemorrhage.
• Diagnose and manage acute and life-threatening endocrine and metabolic derangements.

After completing training, fellows are expected to:

• Diagnose and manage sleep disorders, particularly obstructive sleep apnea.
• Preliminary interpretation and polysomnographic and nap studies.
• Diagnose and manage problems related to continuous positive airway pressure and bilevel pressure therapies.
• Diagnose and manage sleep disorders other than obstructive sleep apnea.

After completing training, fellows are expected to:

• Perform bronchoscopy with endobronchial biopsy, transbronchial biopsy, bronchoalveolar lavage, bronchial washing, and transbronchial needle aspiration.
• Intubate with a laryngoscope and with a bronchoscope.
• Know the proper administration and titration of oxygen, including high flow nasal cannula system.
• Be capable of performing and interpreting pleural fluid drainage. 
• Insert chest tubes and perform pleurodesis of the pleural space.
• Insert central venous catheters, temporary hemodialysis catheters, and arterial catheters and know how to properly calibrate hemodynamic monitoring equipment.
• Be capable of performing arterial puncture and interpreting blood sampling.
• Be capable of performing cardioversion.
• Be capable of performing paracentesis. 
• Understand the indications for hemodialysis and peritoneal dialysis.
• Understand the indications for peritoneal lavage.
• Other procedures that the fellows would encounter during their training but not necessary for program completion including tracheostomy tube placement, pleural biopsy, ECMO cannulation and pericardiocentesis. 
   

After completing training, fellows are expected to:

• Interpret spirometry, bronchodilator studies, diffusing capacity, lung volumes, flow volume loops, and bronchial provocation tests.
• Perform and interpret exercise studies.
• Interpret bronchoalveolar lavage studies.
• Know the indications for immunization against pulmonary diseases.
• Calculate and interpret oxygen content, delivery, and consumption.
• Have knowledge of pulmonary pathology and interpretation of lung and pleural biopsy material.

After completing training, fellows are expected to:

• Identify a clinical or a basic science research problem.
• Develop experimental methods.
• Understand simple concepts of protein analysis and purification.
• Understand simple molecular biological principles and techniques.
• Design clinical or basic science research studies.
• Interpret data and statistical problems related to research studies.
• Prepare and submit grants to seek funding.
• Prepare manuscripts for publication.

The Pulmonary Consult rotation at UMMC is managed predominantly by the P/CC fellow with staff supervision. A senior medical student or medicine resident also may be present, in which case the fellow has significant responsibility for education of the junior trainees.

Inpatients evaluated by the Pulmonary Consult service at the East Bank University campus are complex with high acuity. Fellows will have ample exposure to CF, ILD and lung transplant patient populations (pre-lung transplant on this rotation); pulmonary complications of bone marrow transplantation and other immunocompromised populations such as chemotherapy, immunotherapy, corticosteroids and immune deficiencies. This service also sees patients in the surgical, cardiac and neuro ICUs for both general pulmonary consultation and ventilator management in patients with underlying pulmonary issues such as asthmatics on ECMO. 

Fellows will learn outpatient bronchoscopy techniques for lung transplant patients and are responsible for all inpatient bronchoscopies (except MICU & SICU) that do not require advanced airway interventions (performed by the Interventional Pulmonary service).

The service manages chest tubes, whether placed by the consult service or interventional radiology.

Depending on the schedule, Pulmonary Consult service is responsible for general pulmonary consults at the UMMC West Bank campus, accessed by a short shuttle bus ride across the Mississippi river.

Fellows participate in Pulmonary Service Line telephone “mini-consults” from physicians in the Twin Cities and the five-state Upper Midwest region.

When fellows are on an in-patient weekend shift, they work-up and present new and follow-up consults to the long-call MICU attending.

Medical Intensive Care Unit

We admit patients daily and are responsible for all procedures: central lines, swan-ganz catheters, bronchoscopies, arterial lines, LP, paracentesis, & thoracentesis. The Fellow coordinates all procedures. The Attending must be present for the critical portion of the procedure.

An ultrasound is available and should be used for central line insertions.

Other procedures: intubation. DL or RSI intubations are at the Attendings’ discretion and are sometimes done with anesthesia. We may sometimes intubate patients over a bronchoscope without paralysis because they will get a bronchoscopic exam anyway. Feedings tubes can be placed by nurses, nutrition service or by IR under fluoroscopy.

Bronchoscopies and intubations, placements are assisted by the 4C RT assigned to the procedure room (Usually Paul or Bill). All patients must have a consent, a procedure note in Provation (EMR) and post-procedure orders.

Rounding: Signout from night team at 7:00 AM, pre-rounds --7:15-8:00 am, MICU lecture on some days (schedule in MICU conference room) presented by either the attending or the fellow (slides available on conference room computer). Rounding 8:30 am- 12:00 pm (variable by Attending and number and severity of patients), informal rounds with residents to reassess unstable patients--around 3-4pm.

ICU Rounding team: students, resident, Fellow, Attending, PharmD, pharmacist, pharmacy student, charge nurse, RT (usually in unit, doesn’t round with team unless needed).

All admits to the ICU must be pre-approved by the ICU Attending - the Attending then contacts the Fellow and resident. IF Fellows are called regarding admissions please refer it to the Attending.

Transfers out of the ICU: patients aren’t “accepted” by the floor team until the Attending contacts the accepting Attending; then the ICU resident can call the requisite floor resident. Fellows usually do not need to be involved.

Time off: The Fellow is on every other weekend. The Resident and Intern each get one day off a week.

Weekend Bronchoscopies: The pathologist on call needs to be called to process and look at the cytology/pathology for all bronchs after 3pm Friday and those performed on Saturday and Sunday.

Critical Care Consults: NOTE these are done by the MICU Fellow/team.

Fellows on clinical track will do 21-26 nights per year, while fellows on T32 track will do 14-16 nights. The nights are scheduled 6 in a row, with one day off (24 hours at least) before resuming night rotation or transitioning to a different rotation. The fellow is expected to participate in sign-out from the day team at 6 PM, then coordinate with the in-house night attending, charge nurse and resident for plans for admitted patients in the MICU. The fellow will also help surgical residents admit SICU patients, under the supervision of the night intensivist. All new admissions need to be formally staffed with the attending. The nightshift ends at 7 AM with sign-out to the day team. 

The Consult Team is composed of the Fellow, one or two Medical Residents, and one of the eight Pulmonary Staff who rotate through at one-week intervals. The Consult Service is predominantly outpatient-based, with an average of 6 to 8 new consult patients scheduled each day in the Pulmonary Evaluation Clinic. We also engage in video telemedicine consults to remote VA clinic sites within our large geographic catchment area. The Consult Team is also responsible for inpatient consults, averaging 2 or 3 consults per day from a wide range of settings (e.g. medical and surgical wards, spinal cord injury unit, polytrauma unit, community living center).

Procedures
During your three month rotation, you will have the opportunity to perform bronchoscopies and pleural procedures. The vast majority of these are performed as outpatient procedures; however, you will have the opportunity to perform bronchoscopy and pleural procedures on patients from the wards and ICU. The VA rotation is your primary opportunity to acquire skills for endobronchial procedures. You will also have opportunities to perform navigational bronchoscopies for peripheral lung lesions and central lymph nodes. Bronchoscopies are performed in the Pulmonary Bronchoscopy Suite under the supervision of the Consult attending and are staffed by a pulmonary sedation nurse and a respiratory therapist.

Other Responsibilities
The Fellow is responsible for triaging incoming pulmonary consultation requests and determining which requests will require a face-to-face visit, versus which can be completed using electronic consultation through the VA's robust electronic medical record system. Fellows also interpret pulmonary function testing and have the opportunity to learn about portable sleep testing and treatment of complex sleep-disordered breathing.

Weekly Schedule
Monday – Friday: 8:00 am to 5:00 pm: Consults in the outpatient clinic and inpatient units, procedures, consult triage and teaching.

• Wednesday: 7:30 am: Pulmonary fellows weekly conference (rotating site schedule).
• Wednesday: 12:00 pm: Medicine M&M conference.
• Thursday: 12:00 pm: Medicine Research Conference
• Thursday: 1:00 pm: Pulmonary Continuity Clinic: Pulmonary Clinic is attended by the Fellow, Residents, and all Pulmonary Staff. This is where most follow-up cases will be seen (the Evaluation Clinic is primarily new consultation patients).
• Friday: 8:00 am: Multidisciplinary Chest Conference. Attended by the Consult Team, Pulmonary Staff, Thoracic Surgery, Medical Oncology, Radiation Oncology, Radiology and Nuclear Medicine. Cases of suspected/confirmed lung cancer and other pulmonary diseases are discussed. The Pulmonary Fellow is responsible for ensuring that Pulmonary service cases are presented succinctly (by themselves or by the Residents) and that decisions are recorded in the chart.
• Friday: 12:00 pm: Medicine Grand Rounds.

Pulmonary Fellow’s Role On The HCMC Consult Service
The Pulmonary Consult Service is composed of the Pulmonary Staff, 1-2 Residents and 0-2 medical students. The Fellow is responsible for organizing consult rounds, seeing and discussing all new consults and follow-ups with the Consult Residents/students, educating the Residents/students rotating on the Pulmonary Consult Service regarding issues pertaining to pulmonary medicine, ensuring communication of Pulmonary's recommendations to the Primary Team, arranging and performing bronchoscopies, and performance of or supervision of residents performing other pulmonary procedures (chest tubes, thoracenteses).

Daily Schedule/Rounds
See new in-patient consults and follow ups 9:00-10:30 am(approximately).

Consult Rounds
10:30 - 12:00 and afternoon, either before or after clinic (variable).

Clinic
Pulmonary Clinic (Located on G-1) - All day Monday, Tuesday, and Wednesday and Friday at 1:00 p.m. On M/W/F the clinic is a new patient clinic staffed by the Consult Attending. The Pulmonary Staff also have continuity clinics at the same time/location on M/T/W; the Fellow is expected to take this opportunity to see some of these patients as well, especially if the New Patient Clinic or the Consult Service is slow.

Because procedures or other pressing concerns may occur at these times, the Fellow may not always get to clinic. However, when possible, clinic should be attended.

Many interesting problems, both new and old, are seen in the outpatient area and the Fellow should be an integral part of the decision-making process here.

Procedures
The Fellow is responsible for bronchs, chest tubes, Cope biopsies, and difficult thoracentesis. The Fellow may supervise thoracentesis if the G-1 or G-2 has not had much experience. As the Fellow gains experience with chest tubes, he/she will also supervise the G-2. (Should discuss placement of chest tubes with Pulmonary Staff prior to procedure, unless emergent).

On-Call
While on the Consult Rotation, the Fellow will take call in the HCMC MICU every 2-3 weekends, and about 1-2 weeknights/week. While on call, the Fellow is the acting Critical Care Fellow, and the expectations/responsibilities are the same (see HCMC MICU rotation).

Pulmonary Fellow’s Role in the HCMC MICU
During their month in HCMC MICU, the PF assumes the role of the HCMC Critical Care Fellow. This role includes evaluation and discussion with the admitting team of all new admissions and patients with active problems in the MICU, supervision of residents performing ICU procedures, and education of the residents rotating on the MICU service regarding issues pertaining to intensive care medicine. For patients on the MICU service the PF is not required to write notes.

The fellow is also responsible for providing ICU consultation on all patients on the Nephrology Service in the MICU (in general these are the only patients in the MICU that are not on the MICU service, but they tend to be sick and complex). The Fellow should fill out a consultation form and staff the new Nephrology Service patients with the On Call MICU Staff. Rarely, critically ill patients on the Neurology Service will board in the MICU; they should also receive a critical care consultation.

Patient Rounds
On weekdays there are 2 MICU staff and 4 MICU teams (2 teams per staff). The Fellow will typically round in the morning with the staff and 2 teams that are post-call. In this way the Fellow will be able to see all new admissions. After morning rounds (around 11:30) the Fellow should check with the other MICU staff and teams to see if there are active issues or procedures to be done on their patients.

Monday-Friday

• 7:30 - 9:00 p.m.: Pre-round on new admissions and patients with emergent /active issues.
• 9:00 a.m. - 12:00 p.m. (Noon): See new patients and review old patients during rounds in the ICU.
• 12:00 p.m. (Noon) - 1:00 p.m.: Departmental Conferences
• 1:00 - 4:00 p.m.: Help in ICU, e.g. Procedures, new patients’ evaluation, discussion with residents.
• 4:30 - 5:30 p.m.: Late afternoon MICU rounds, emphasis on likely problems for upcoming night and walk through sign-out with the on-call Fellow.

On-Call
Every 2-3 weekends and about 1-2 weeknights/week. Night call is from home. When Fellows are on call, it is expected that they page the Admitting On-Call Senior Resident around 10:00 pm to discuss new admissions and active problems. The Staff on-call is always available for phone consultation or to come to the hospital to see a patient.

ICU Procedures

• The MICU staff is always available to supervise any procedure. Staff supervision is required for all bronchoscopies.
• Fellow has primary role in bronch, chest tubes, thoracentesis supervision.
• Fellow will supervise Swan, A-line, central lines, etc.
• Fellow should use MICU Staff as first line resource when problems arise with procedures: e.g. difficulty in identifying waveforms during Swan placement or suspected technical problems with pressure monitoring system. (Biomedical and ICU nurses are also helpful resources here).

Intubations
Depending on the individual's level of experience, the fellow may have the opportunity to do ICU intubations with either Anesthesia or MICU Staff permission and backup. Before performing intubations in the MICU, the PF should have had significant previous experience with intubation in a non-emergent setting (e.g. the OR).

Clinic
Fellows do not attend clinic during their month in the HCMC MICU.

Facilities/Resources
The fellow shares an office with the CCFs (Rm # G 5.242) which contains current textbooks on Pulmonary and Critical Care, computers with access to Up To Date and OVID, the computerized medical record (EPIC), and Isite for on-line radiology viewing.

Objective
The primary goal of this Critical Care rotation is to provide a medical critical care experience in a community-based hospital. The Fellow will care for a variety of patients with critical illness under the direct supervision of the Park Nicollet Pulmonary, Sleep, and Critical Care Medical Staff. Some patients are the primary responsibility of the Fellow and staff; some are cared for on a consultative basis. When co-managing a case, discussion with the Primary Attending will determine the division of responsibility.

Call
The Fellow will be on call for the ICU approximately 10 days during the month. These 10 days will include 2 weekends (Saturday and Sunday). There is staff backup at all times. The staff will field general ward calls, and new ward, ER, or Urgent Care consultations. Ward and outpatient phone calls are sent directly to the Attending On Call. The Fellow is responsible for ICU coverage and will be notified by a Consulting MD or the Attending Staff of a new after-hours consultation. The Fellow should contact the On-Call Staff with any new admissions or if there are any questions regarding current patients.

Intubations
The Fellow is allowed to perform intubations with supervision. Unless emergent, Anesthesia should be present at the initiation of the intubation to function as backup. If emergent, the intubation may be started with Anesthesia en route.

Procedures
Bronchoscopies and chest tubes require the personal attendance of the supervising Pulmonary/ICU MD. The Attending should be aware that the Fellow is placing arterial and central lines but does not need to be in the room unless the Fellow requires assistance (this will depend on the previous experience of the Fellow). A portable ultrasound is available and should be used for all central line placements. Interventional Radiology is also available to assist if needed. Attending staff should be in the ICU and notified when a pulmonary artery catheter is placed.

Mechanical Ventilation
We work closely with Respiratory Therapy. At the beginning of each rotation the Fellow will meet with the head of the Respiratory Therapy Department for orientation to our specific ventilators and weaning protocols. At the initiation of mechanical ventilation, initial ventilator orders and respiratory medications should be entered into Lastword. This is located in the order sets. If the Fellow/Attending makes a ventilatory change they must write it down on the ventilator flow sheet (located on the ventilator) and initial or personally communicate to the ICU Respiratory Therapist. An order directly into Lastword is preferable, but in an emergent situation this can be done with a verbal order to the nurse or therapist. If the ventilator change is not documented, then it is assumed it was made in error and the ventilator will be placed on the previous settings. An incident report may be generated as well.

Infection Control
Please follow all isolation signs (VRE, MSRA etc). Wash hands or use the bactericidal rinse located at the door of each room. Use the purple gloves and individual stethoscopes on all patients. If a patient-specific stethoscope is not available, clean your stethoscope with the germicidal cloths (Asepti-Wipe) located on the stand outside of the patient’s room. Utilize full sterile technique for procedures (including mask, gown, and gloves). If in doubt, always feel free to ask.

Available Protocols

• Sedation Protocol
• Ventilator Weaning Protocol
• Heparin infusion Protocol
• Potassium replacement Protocol
• Ventilator Orders
• Glucose Protocol

Miscellaneous
Staff is available at all times for case discussion and to assist with patient care.

Fellows participate for one month in the care of patients admitted to the SICU at either the University of Minnesota Medical Center - Fairview (UMMC-F): a 24-bed SICU, or Regions Hospital. These SICUs offer an in-depth experience in the postoperative management of patients undergoing a variety of surgical procedures including organ transplant, coronary artery bypass grafting, resection of lung masses, trauma, and other surgical procedures. Patient care involves a multidisciplinary approach including intensivists, surgeons, anesthesiologists, pharmacists, dietitians, and specialists in Internal Medicine. The fellow is an active member of the patient-care team and attends daily rounds, may be primarily in charge of patient care, takes night call every fourth night (UMHC only), and provides consultative services for all the patients in the SICU.

The opportunity for fellows to act as primary care or consulting attending physician in the MICU is available at all four sites. This is a one-month elective in which the fellow is viewed as the attending physician in the ICU with a designated faculty attending physician available for assistance. It is the intention of the training program to provide an opportunity to senior fellows to assume an attending role in a supportive environment in preparation for their clinical duties upon graduation. Fellows are either primarily in charge of a patient-care team consisting of medical residents/interns and medical students or act as consultant to the ICU. Night call is every fourth night (UMMC-F and Regions Hospital) and weekend call is 1 to 2 weekends in the month-long rotation.

The Sleep Medicine rotation is a formal part of the curriculum to attain training and specialty board examination eligibility in Pulmonary Medicine at the University of Minnesota School of Medicine/ University of Minnesota Health. The Sleep Medicine rotation is available to individuals after the completion of 1 year of fellowship training. The 2-week rotation has been designed to provide an educational experience that assures its Pulmonary fellows will possess sound clinical judgment and a high level of knowledge about the diagnosis, treatment, and prevention of common sleep disorders. For those individuals that would like to develop a comprehensive multi-disciplinarian knowledge about the complexities of sleep medicine as well as developing formal polysomnographic interpretive skills and the establishment of a well-managed accredited Sleep Laboratory/Center, a formal one year Clinical Sleep Medicine Fellowship is a possibility for those who have completed their Pulmonary Medicine Fellowship.

• Anesthesiology
• Lung Transplantation & Adult Cystic Fibrosis (aka FIRM)
• Neuro Critical Care
• Tuberculosis
• PFT
• Interventional Pumonology
• Bone Marrow Transplantation
• Burn ICU (Regions Hospital)
• Cardiovascular Surgery
• Consultative Cardiology
• Dialysis/Renal
• Echocardiography
• Thoracic Radiology 
• Infectious Disease
• Pediatric ICU
• Respiratory Care
• Coronary Intensive Care Unit