CRITICAL CARE MEDICINE FELLOWSHIP
George Washington University Medical Center
CRITICAL CARE MEDICINE FELLOWSHIP
Medicine Critical Care Fellowship |
Anesthesiology Critical Care Fellowship |
Fellowship Coordinator |
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Scope and Duration of Training
Program Director/Faculty
Facilities and Resources
Educational Program
Scholarly Activity
Evaluation
Upon completion of residency training, the physician should have achieved proficiency in the recognition and initial management of problems commonly encountered in the intensive care unit. This proficiency includes sepsis, acute respiratory failure, acute renal failure, hemodynamic instability, overdoses and poisonings, acute neurologic insults, acute electrolyte and endocrine emergencies, and coagulation disorders. For less common problems, the trainees gain a knowledge base that allows them to formulate a differential diagnosis, initiate a management plan, and request appropriate consultations.
The CCM program at George Washington University Medical Center (GWUMC) consists of 12 months of full-time training for Anesthesiology, Surgical and Internal Medicine Sub-Specialty graduates, 24 months for fellows who begin following a core internal medicine program. At least 75 %of training in these programs will be spent in the care of critically ill patients in intensive care units (ICUs). The remainder may be in clinical activities or research relevant to critical care.
The subspecialty program in CCM is centered in a 48 bed mixed medical/surgical intensive Care unit (ICU), with cardiothoracic, neurosurgical and trauma patients. The program is structured to assure optimal patient care while providing its trainees the opportunity to develop skills in clinical care and judgment, teaching, administration and research. The ICU at GWUMC provides a wide variety of clinical problems in critical care medicine, with continuous interaction with all the disciplines of medicine and surgery. This provides the experience necessary development of broad clinical skills required for a subspecialist in CCM.
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Michael Seneff, M.D. Associate Professor Anesthesiology and Critical Care Medicine Medical Director, Intensive Care Unit Program Director, Critical Care Medicine Fellowship, Internal Medicine |
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Christopher Junker, M.D Assistant Professor Anesthesiology and Neurosurgery Program Director, Critical Care Medicine Fellowship, Anesthesiology |
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Guillermo Gutierrez, MD, PhD Professor of Medicine Chairman, Division of Pulmonology Program Director, Pulmonary and Critical Care Medicine |
| Bruce Abell, MD Assistant Professor of Surgery |
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| Lakhmir Chawla, MD Department of Anesthesiology & Critical Care Medicine and Division of Renal Diseases and Hypertension Assistant Professor of Medicine Director, ICU Research |
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Seth Akst, MD, MBA Assistant Professor Anesthesiology & Critical Care Medicine |
Facilities and Resources (Return to Top)
Subspecialty training in CCM occurs principally in the ICU. The ICU is capable of providing acute and long-term life support of patients with multiple organ system derangements. The ICU at GWUMC is a multidisciplinary 48 bed mixed medical/surgical unit, with cardiothoracic, neurosurgical and trauma patients.
The CCM residents receive a large range of exposure to patients. The average daily census is XXX. There is only one CCM resident on the service at a time.
1. The ICU is staffed by nurses certified in critical care medicine. Technicians with expertise in biomedical engineering supervise the operation and maintenance of equipment. At least one dedicated respiratory therapist is on the unit at all times. This may be increased to two, depending on the number of patients receiving mechanical ventilation.
2. The Department of Pathology, located in the basement of the hospital, provides facilities for laboratory measurements pertinent to care of critically ill patients with multiple organ system derangements. These include measurement of blood chemistries, blood gases and pH, culture and sensitivity, toxicology, and analysis of plasma drug concentrations. Point of care testing is also available in the ICU for core laboratory studies.
3. The Department of Radiology, located on the first and second floors of the hospital, provides facilities for special radiologic imaging procedures, including magnetic resonance imaging, computed tomography, plain x-rays, ultrasound, interventional and angiography. The Department of Cardiology, located two floors below the ICU, provides facilities and equipment for vascular imaging and echocardiography.
4. The ICU has all appropriate monitoring and life-support equipment, readily available and representative of current levels of technology. Each ICU bed has a dedicated monitor that can support pulmonary artery catheterization, invasive and non-invasive blood pressure monitoring, capnography, pulse oximetry, and intracranial pressure monitoring. The equipment necessary to carry out these functions is stored in the ICU.
The Himmelfarb Health Sciences Library, in the George Washington University Medical School, is conveniently located next door to GWUMC. The library contains 96, 127 titles and subscribes to 1225 journals. The library has many electronic resources and supplies assess to OVID search programs and MD Consult off campus.
The National Library of Medicine, at the NIH, is easily accessible from our campus by Metro to the NIH.
Space for research is available in the Anesthesiology laboratory located in the School of Medicine. Several rooms for teaching conferences in CCM are available, including a conference room located just outside the ICU. There is a departmental and divisional library with adequate material relevant to critical care. This is supplemented by private faculty book collections in offices located adjacent to the ICU.
The ICU fellow will progress through three levels of training. Described below, these levels are composed of knowledge expectations and appropriate levels of source material, procedural skills, and overal performance objectives for didactic and clinical activities.
Critical Care Curriculum
A. Calendar
1. Level I
a. Knowledge:
The ICU Book / Paul L. Marino.
Handbook of mechanical ventilatory support / [edited by] M. Christine Stock, Azriel Perel
ACLS
ATLS
Understands the major principles and has a working knowledge of the following topics.
Cardiopulmonary resuscitation
Airway management in the critically ill
Management of respiratory failure and mechanical ventilation
Differential diagnosis and treatment of shock
Support of the failing circulation
Diagnosis and treatment of cardiac arrhythmias
Management of the post cardiopulmonary bypass patient
Trauma management
Neurologic critical care, including management of increased intracranial pressure
Management of sepsis/SIRS syndrome
Multiple organ system failure syndrome
Management of the immunocompromised patient
Management of gastrointestinal bleeding in the ICU
Metabolic, endocrine and acid-base abnormalities in the ICU
Sedation and pain management for the critically ill patient
Nutritional support in the ICU
Antibiotic therapy and infections
b. Skills:
1. Ventilation by bag and mask
2. Suction techniques
3. Fiberoptic laryngotracheobronchoscopy
4. Management of pneumothorax (needle, chest tube insertion, drainage systems)
Arterial puncture and blood sampling
2. Insertion of monitoring catheters
a. central venous
b. Arterial
c. Pulmonary artery catheters
d. Uses specified antiseptic technique
Communicates effectively with patients, and family
Communicates effectively with attendings, housestaff and nurses
c. Performance
Presents cases to the ICU attending in a concise and thorough manner that includes all important factors contributing to the patient's critical illness.
Demonstrates appropriate management skill surrounding basic issues for each of the topics listed about (Knowledge section), and seeks out appropriate sources of information for decisions on more complicated issues.
Actively participates in morning report, teaching rounds, and ICU conferences.
Interacts well with fellow physicians, nurses, and support staff, both in the ICU and in the hospital.
Demonstrates appropriate rapport with patients and their families.
Satisfactory participation in the Quality Assurance Program of the Division of Critical Care Medicine.
Meets the standards for clinical competency commensurate with level of training as set forth by the Department of Anesthesiology/Critical Care Medicine.
Successfully functions as a resident in the standard call rotation, taking admissions on call every third or fourth night.
Progressively expands knowledge of the entire service and participates in management decisions regarding all patients.
Demonstrates readiness to take fellow call, consisting of daily management, under supervision, of the entire service, and receiving resident calls at night and performing initial evaluation of admissions, and then discussing them with the attending.
Demonstrates qualities and attributes fundamental to performance as a consultant in Critical Care Medicine
Ability to organize and express thoughts clearly
Sound judgment in decision-making and application
Ability to apply basic science principles to clinical situations
Adaptability to rapidly changing clinical conditions
Independent to the level of experience and knowledge
Recognizes error or irrelevancy
Level II
Continues to meet prior objectives
a. Knowledge:
Irwin and Rippe's Intensive Care Medicine / editors, Richard Irwin, Frank B. Cerra, James M. Rippe.
Principles and practice of intensive care monitoring / editor, Martin J. Tobin.
Principles and practice of mechanical ventilation / editor, Martin J. Tobin.
Understands and can teach the principles behind cardiopulmonary resuscitation
Management of mechanical ventilation for COPD and ARDS
Integrated differential diagnosis and treatment of shock using monitoring, laboratory analysis, and clinical presentation
Relative advantages of circulatory support drugs
Treatment of cardiac arrhythmias beyond standard ACLS
Principles of management of vasosopasm in brain injury
Manifestations of multiple organ injury in sepsis/SIRS
Management of the febrile neutropenic patient
Management of variceal bleeding and hepatic insuffficiency
Metabolic, endocrine and acid-base abnormalities in the ICU
Pharmacokinetics and clinical effects of sedation regimens in the ICU, and the use of the Ramsey scale of sedation
Advantages of enteral vs. parenteral feeding
Antibiotic drug level monitoring
b. Skills:
With assistance from the attending, the CCM resident, when appropriate, supervises and teaches:
1. Ventilation by bag and mask
2. Suction techniques
3. Fiberoptic laryngotracheobronchoscopy
4. Management of pneumothorax (needle, chest tube insertion, drainage systems)
5. Arterial puncture and blood sampling
6. Insertion of monitoring catheters
a. central venous
b. Arterial
c. Pulmonary artery catheters
d. Uses specified antiseptic technique
Communicates effectively with patients, and family in situations where a poor outcome is expected
Organizes and communicates effectively housestaff including effective signout rounds and follow up to plans developed on rounds.
Communicates effectively with nurses concerning specifics of patients care plans, and problems they may incounter.
Communicates effectively with attending in the ICU regarding status of patients in the ICU and the progress of care plans.
Communicates effectively with attendings whose patients are admitted to the ICU.
c. Performance
Presents cases to the ICU attending, and presents an initial plan of care in a concise and thorough manner.
Demonstrates appropriate management skill for presentations previously discussed or encountered, the CCM can initiate a plan of care effectively prior to informing the attending
Collects information for, and presents cases at M & M, and presents articles selected by or with the approval of the attendings in the ICU.
Successfully functions on CCM resident call, keeping track of all pertinent patient information regarding presentation, test results, plan of care, and current status for all admissions.
Progressively expands ability to formulate and initiate diagnostic and care plans without first consulting the attending, while keeping attending informed of all decisions made.
Level III
Continues to meet prior objectives.
Knowledge:
Critical Care Medicine
Chest
Articles selected by attendings covering topics arising from patient care
Literature searches
Takes and reviews results for the MCCKAP test
NIH or comparable board review course
b. Skills:
The CCM resident, when appropriate, supervises and teaches most procedures without assistance.
Conducts family conferences concerning prognosis, end of life care, DNR, withdrawal of support with occasional help from the attending where appropriate.
Occasionally conducts rounds without the attending present, and communicates a summary of the care plans developed to the attending.
Communicates effectively consulting physicians concerning appropriate studies, results and therapies.
c. Performance
Performs initial evaluation on most admissions and formulates treatment plans, including appropriate consultations without assistance.
In addition to Journal Club, and M & M, the CCM resident begins to take responsibility for some of the Noon conferences.
Cogently discusses management plans with the parent services of any shared patients in the ICU.
Conducts rounds with residents, demonstrating the significance of physical findings and monitor information at the bedside.
ACC residents will acquire clinical experience in the following areas:
1. Airway maintenance and management
2. Mechanical ventilation
3. Devices that supply supplemental oxygen
4. Indications and techniques for emergency and therapeutic treatment of conditions requiring thoracentesis and/or tube thoracostomy.
5. Emergency and therapeutic fiberoptic laryngotracheobronchoscopy
6. Assessment and evaluation of pulmonary function
7. Cardiopulmonary resuscitation.
8. Placement and management of arterial, central venous and pulmonary artery catheters
9. Emergency and therapeutic placement of pacemakers
10. Pharmacologic and mechanical support of circulation
11. Evaluation and management of central nervous system dysfunction
12. Recognition and treatment of hepatic and renal dysfunction
13. Diagnosis and treatment of sepsis
14. Fluid resuscitation and management of massive blood loss
15. Enteral and total parenteral nutrition
16. Bioengineering and monitoring
17. Interpretation of laboratory results
18. Psychiatric effects of critical illness
19. Transesophageal echocardiography (TEE)
20. Ethical aspects of critical care
Skills
A. Airway Management
1. Maintain airway patency, mask ventilation, use of laryngeal mask airway.
2. Direct laryngoscopy, endotracheal intubation.
3. Management of difficuly airway with intubatating stylette, light wand intubating LMA.
4. Intubation with fiberoptic bronchoscope.
B. Breathing, Ventilation
5. Chest physiotherapy, incentive spirometry
6. Monitoring airway pressures
7. Operation of mechanical ventilators
8. Measurement of endotracheal tub cuff pressures
9. Interpretation of sputum Gram stain
10. Performance of bedside pulmonary function tests
11. Application of appropriate oxygen therapy
12. Application of end tidal CO 2 detectors, pulse oximeters, oximetric pulmonary artery catheters
13. Radiograph interpretation
C. Circulation
1. Arterial puncture and blood sampling
2. Insertion of monitoring catheters
a. central venous
b. Arterial
c. Pulmonary artery catheters
3. Pericardiocentesis
4. Management of arterial and venous air embolism
5. Transvenous pacemaker insertion
6. Cardiac output determinations using thermodilution
7. Obtain 12-lead electrocardiogram
8. Use of infusion pumps for vasoactive drugs
9. Cardioversion, defibrillation
10. Application and regulation of intra-aortic assist devices
11. Application of noninvasive cardiovascular monitors
12. Transcutaneous pacing
D. Central Nervous System
1. Lumbar puncture
2. Monitoring of modified electroencephalogram
3. Application of hypothermia
E. Renal
1. Manage peritoneal dialysis
2. Manage CAVH, CVVH
3. Insertion of hemodialysis catheters
F. Gastrointestinal Tract
1. Insertion of transesophageal devices
2. Prevention and management of upper gastrointestinal bleeding
G. Hematology
1. Utilization of blood component therapy
2. Management of massive transfusions, including rapid infusers
3. Autotransfusion
4. Proper ordering and interpretation of coagulation studies
H. Infection
1. ICU sterility techniques and precautions
2. Sampling, staining, interpretation of blood, sputum, urine, body fluids and drainage
I. Metabolism, Nutrition
1. Enteral feeding access
2. Parenteral nutrition
1. Airway maintenance and management
a. Develop skills in airway management, with special reference to the problems unique or common to critical care patients.
b. Performs and then supervises procedures in all situations in which airway maintenance and management are required.
2. Mechanical ventilation
a. Develop skills using pressure and volume ventilators
b. Uses positive end-expiratory pressure, intermittent mandatory ventilation, continuous positive airway pressure, inverse ratio ventilation, pressure support ventilation, negative pressure, pressure control, and noninvasive ventilation.
c. Recognizes indications for and hazards of mechanical ventilation
d. Recognizes and treats barotrauma and volutrauma
e. Implements criteria for weaning and weaning techniques
f. Uses permissive hypercapnia in appropriate situations.
3. Devices that supply supplemental oxygen
a. Recognizes the degree and type of respiratory disturbance.
b. Develops ability to select appropriate device for supplying oxygen including venti-mask, non-rebreather masks and nasal cannulas
4. Indications and techniques for emergency and therapeutic treatment of conditions requiring thoracentesis and/or tube thoracostomy.
a. Recognizes the need for emergency or therapeutic treatment of conditions requiring thoracentesis and/or tube thoracostomy.
b. Performs and then supervises all thoracentesis and tube thoracostomy procedures.
5. Emergency and therapeutic fiberoptic laryngotracheobronchoscopy
a. Recognizes appropriate indications for fiberoptic equipment.
b. Performs and then supervises all fiberoptic laryngotracheobronchoscopies.
6. Assessment and evaluation of pulmonary function
a. Evaluates pulmonary function tests including assessments of ventilator weaning success
b. Evaluates arterial blood gas measurements.
7. Cardiopulmonary resuscitation.
a. Certified in ACLS and ATLS prior to completion of their CCM training.
8. Placement and management of arterial, central venous and pulmonary artery catheters
a. Recognizes clinical indications for invasive monitoring.
b. Able to interpret wave forms and measurements, and develop therapeutic strategies based on these observations.
c. Learns to recognize poor wave forms and trouble shoot problems with catheters and monitoring equipment.
9. Emergency and therapeutic placement of pacemakers
a. Recognizes clinical indications for transcutaneous and trans venous pacing.
b. Can program, recognize capture, and select modes of pacing suitable to the clinical goal.
10. Pharmacologic and mechanical support of circulation
a. Recognizes the clinical indications for pharmacological support of the circulation.
b. Selects agents on the basis of likely or known abnormalities in the circulation
and uses them appropriately.
11. Evaluation and management of central nervous system dysfunction
12. Recognition and treatment of hepatic and renal dysfunction
13. Diagnosis and treatment of sepsis
14. Fluid resuscitation and management of massive blood loss
15. Enteral and total parenteral nutrition
16. Bioengineering and monitoring
17. Interpretation of laboratory results
18. Psychiatric effects of critical illness
19. Transesophageal echocardiography (TEE)
a. Develop skill at interpreting TEE images by following up individual studies with cardiology to understand their findings.
b. Department of Anesthesiology course in TEE
20. Ethical aspects of critical care
a. ACC residents first observe attending interactions with other attendings, family members and patients regarding end of life care, limitations, surrogate decision making, and futility.
b. Residents develop ability to
2. Living wills, advance directives, durable powers of attorney
Didactic component goals are met with a combination of patient care rounds, special courses, daily noon conferences, M & M, and supplemental reading. Approaches to resident teaching vary with available facilities, patient population base, and faculty.
1.Resuscitation
2.Cardiovascular physiology, pathology, pathophysiology and therapy
3.Respiratory physiology, pathology, pathophysiology and therapy
4.Renal physiology, pathology, pathophysiology and therapy
5.Central nervous system physiology, pathology, pathophysiology and therapy
6.Pain management of critically ill patients
7.Metabolic and endocrine effects of critical illness
8.Infectious disease physiology, pathology, pathophysiology and therapy
9.Hematologic disorders secondary to critical illness
10.Gastrointestinal, genitourinary, and obstetric-gynecologic acute disorders
11.Trauma, including burns
12.Monitoring, bioengineering, biostatistics
13.Life-threatening pediatric conditions
14.End of life care
15.Pharmacokinetics and dynamics; drug metabolism and excretion in critical illness
16.Transport of critically ill patients
17.Administrative and management principles and techniques
18.Medical Informatics
19.Cost effective care
20.Ethical and legal aspects
21.Effective interpersonal and communication skills with patients, family members, and other health care providers
1.Resuscitation
a. ACLS
2.Cardiovascular physiology, pathology, pathophysiology and therapy
a. Shock and its complications
b. Myocardial infarction and its complications
c. Cardiac rhythm and conduction disturbances; indications for and types of pacemakers
d. Pulmonary embolism: thrombus, air, fat, amniotic
e. Pulmonary edema; cardiogenic, noncardiogenic
f. Cardiac tamponade and other acute pericardial diseases
g. Acute and chronic life-threatening valvular disorders
h. Acute aortic and peripheral vascular disorders including A-V fistula
i. Acute complications of cardiomyopathies and myocarditis
j. Vasoactive and inotropic therapy
k. Pulmonary hypertension and cor pulmonale
l. Complications of angioplasty
m. Principles of oxygen transport
n. Hemodynamic effects caused by ventilatory assist devices
o. Thrombolytic and anticoagulant therapy
p. Perioperative management of patient undergoing cardiovascular surgery
q. Recognition, evaluation, and management of hypertensive emergencies and urgencies
3.Respiratory physiology, pathology, pathophysiology and therapy
a.. Acute respiratory failure
i. Hypoxemic respiratory failure including ARDS
ii. Hypercapnic respiratory failure
iii. Acute on chronic respiratory failure
b. Status asthmaticus
c. Smoke inhalation, airway burns
d. Aspiration
e. Flail chest, chest trauma, pulmonary contusion
f. Bronchopulmonary infections
g. Upper airway obstruction
h. Near drowning
i. Pulmonary mechanics and gas exchange
j. Oxygen therapy
k. Hyperbaric oxygenation
l. Mechanical ventilation
i. Pressure and volume ventilators
ii. Positive end-expiratory pressure, intermittent mandatory ventilation, continuous positive airway pressure, high frequency ventilation, inverse ratio ventilation, pressure support ventilation, negative pressure ventilation, differential lung ventilation, pressure control, and noninvasive ventilation
iii. Indications for and hazards of mechanical ventilation
iv. Barotrauma and volutrauma
v. Criteria for weaning and weaning techniques
vi. Extracorporeal membrane oxygenation
vii. Permissive hypercapnia
viii. Liquid ventilation
ix. Long-term intubation vs. tracheostomy
m. Ventilatory muscle physiology, pathophysiology, and therapy, including polyneuropathy of the critically ill, and the prolonged effect of neuromuscular blockers
n. Pleural diseases
a. Empyema
b. Massive effusion
c. Pneumothorax
d. Hemothorax
o. Pulmonary Hemorrhage and massive hemoptysis
p. Nitric oxide
4. Renal physiology, pathology, pathophysiology and therapy
a. Renal regulation of fluid balance and electrolytes
b. Renal failure: Prerenal, renal, and postrenal
c. Derangements secondary to alterations in osmolarity and electrolytes
d. Acid-base disorders and their management
e. Principles of hemodialysis, peritoneal dialysis, ultrafiltration, continuous arteriovenous and veno-venous hemofiltration
f. Interpretation of urine electrolytes
g. Evaluation of oliguria
h. Drug dosing in renal failure
i. Rhabdomyolysis
5.Central nervous system physiology, pathology, pathophysiology and therapy
a. Coma
i. Metabolic
ii. Traumatic
iii. Infectious
iv. Mass lesions
v. Vascular-anoxic or ischemic
vi. Drug induced
b. Hydrocephalus
c. Psychiatric emergencies
d. Perioperative management of patient undergoing neurologic surgery
e. Brain death evaluation
f. Diagnosis and management of persistent vegetative states
g. Management of increased intracranial pressure
h. Status epilepticus
i. Neuromuscular disease causing respiratory failure
i. Guillan Barré
ii. Amyotrophic lateral sclerosis
iii. Myasthenia gravis
j. Nontraumatic intracranial bleed
i. Subarachnoid
ii. Intracerebral
iii. Epidural and subdural
k. Embolic and thrombotic stroke
6.Pain management of critically ill patients
7.Metabolic and endocrine effects of critical illness
a. Colloid osmotic pressure
b. Nutrition
i. Evaluation of nutritional needs
ii. Enteral and parenteral feeding
` c. Endocrine
i. Disorders of thyroid function (thyroid storm, myxedema coma, sick euthyroid syndrome)
ii. Adrenal crisis
iii. Disorders of antidiuretic hormone metabolism
iv. Diabetes mellitus
a. Diabetic ketoacidosis
b. Hyperosmolar nonketotic coma
v. Hypoglycemia
vi. Pheochromocytoma
vii. Insulinoma
viii. Disorders of calcium and magnesium balance
d. Temperature-related Injuries
i. Hyperthermia
ii. Hypothermia
8.Infectious disease physiology, pathology, pathophysiology and therapy
a. Antibiotics
i. Antibacterial agents including aminoglycosides, penicillins, cephalosporins, and quinolones
ii. Antifungal agents
iii. Antituberculosis agents
iv. Antiviral agents
. Agents for parasitic infections
b. Infection control for special care units
i. Development of antibiotic resistance
ii. Universal precautions
iii. Isolation and reverse isolation
c. Anerobic infections
d. Systemic Inflammatory Response Syndrome
e. Tetanus
f. Hospital acquired and opportunistic infections in the critically ill
g. Adverse reactions to antimicrobial agents
g. Intensive care unit support of the immunocompromised patient
i. AIDS
ii. Transplant
iii. Oncologic
h. Infectious risks to healthcare workers
i. Evaluation of fever in the ICU
9. Hematologic disorders and critical illness
1. Acute defects in hemostasis
a. Thrombocytopenia/thrombopathy
b. Disseminated intravascular coagulation
2. Anticoagulation; fibrinolytic therapy
3. Principles of blood component therapy
a. Platelet transfusion
b. Packed red blood cells
c. Fresh frozen plasma
d. Specific coagulation factor concentrates
e. Albumin, plasma protein fraction
f. Stroma free hemoglobin
g. White blood cell transfusion
h. Cryoprecipitate
4. Acute hemolytic disorders including thrombotic microangiopathies
5. Acute syndromes associated with neoplastic disease and antineoplastic therapy
6. Sickle cell crisis
7. Plasmapheresis
8. Prophylaxis against thromboembolic disease
10.Gastrointestinal, genitourinary, and obstetric-gynecologic acute disorders
1. Acute pancreatitis
2. Upper gastrointestinal bleeding
3. Lower gastrointestinal bleeding
4. Acute and fulminant hepatic failure
5. Toxic megacolon
6. Acute perforations of the gastrointestinal tract
7. Ruptured esophagus
8. Acute inflammatory diseases of the intestine
9. Acute vascular disorders of the intestine
10. Obstructive uropathy, acute urinary retention
11. Toxemia of pregnancy; amniotic fluid embolism, HELLP syndrome
12. Hydaditiform mole
13. Perioperative management of surgical patients
14. Stress ulcer prophylaxis
15. Drug dosing in hepatic failure
16. Cholycystitis
17. Urinary tract bleeding
18. Perioperative complications including fistulas, wound infections, and dehiscence
11.Trauma, including burns
a. ATLS
b. Monthly, combined department, Trauma conference
1. Initial approach to the management of multiple system trauma
2. CNN trauma
3. Skeletal trauma including facial and pelvic fractures
4. Chest trauma-blunt and penetrating
5. Abdominal trauma-blunt and penetrating
6. Crush injury
7. Burns
8. Electrical injury
12.Monitoring, bioengineering, biostatistics
1. Utilization, zeroing, calibration of transducers
2. Use of amplifiers and recorders
3. Trouble-shooting equipment
4. Correcting basic electrical safety hazards
1. Prognostic indices, severity, and therapeutic intervention scores
2. Principles of electrocardiographic monitoring
3. Invasive monitoring
a. Principles of strain gauge transducers
b. Signal conditioners, calibration, gain, adjustment
c. Display techniques
d. Principles of arterial, central venous, and pulmonary artery catheterization and monitoring
e. Assessment of cardiac function and derived hemodynamic parameters
4. Noninvasive hemodynamic monitoring
6. Thermoregulation
7. CNS monitoring (intracranial pressure, cerebral blood flow, cerebral metabolic rate, electroencephalogram, jugular venous bulb oxygenation, transcranial Doppler)
8. Respiratory monitoring (airway pressure, intrathoracic pressure, pulse oximetry, dead space, compliance, resistance, capnography)
9. Metabolic monitoring (oxygen consumption, carbon dioxide production, respiratory quotient)
13.Life-threatening pediatric conditions
14.End of life care
15.Pharmacokinetics and dynamics; drug metabolism and excretion in critical illness
Pharmacology: Uptake, Metabolism and Excretion f Drugs in Critical Illness
1. Antibiotics
2. Antiarrhythmics
3. Chemotherapeutic agents
4. Neuromuscular blockers
5. Sedatives
6. Analgesics
7. Others
Drug overdose and withdrawal
a. Barbiturates
b. Narcotics
c. Salicylates
d. Alcohols
e. Cocaine
f. Tricyclic antidepressants
g. Acetaminophen
h. Others
3. Envenomation
4. Poisoning
a. Cyanide
b. Organophosphates
c. Others
16.Transport of critically ill patients
Use of special beds (roto bed, flexicare)
17.Administrative and management principles and techniques
1. Management of critical care training programs, including documentation and reimbursement issues for attendings in academic practices
2. Organization and staffing of critical care units
3. Standards for special care units, Joint Commission on Accreditation of Healthcare Organizations
4. Medical record keeping
a. Problem-oriented record approach
b. System-structures record approach
c. Manual vs. computer record generation
d. Organization of physician, nursing, technical, and laboratory records
5. Collaborative practice principles
6. Participation in relevant hospital committees
7. Design of ICU's
8. Emergency medical systems in prehospital care
9. Performance improvement, principles and practice
10. Principles of triage and resource allocation
11. Utilization management
a. Case management
b. Clinical practice guidelines
12. Critical pathway development
13. Electronic database
14. Medical economics
a. Reimbursement
b. Healthcare legislation
c. Managed care
15. Budget development and management
18.Medical Informatics
1. Use of computers in critical care units
2. Electronic medical records
19.Cost effective care
20.Ethical and legal aspects
1. Death and dying
2. The ethical decision-making process
3. Forgoing life-sustaining treatment and orders not to resuscitate
4. Principles of pain management
5. Use of surrogate decision-makers
6. Futile care
7. Treatment of demented and mentally retarded patients
8. Rights of patients, the right to refuse treatment
9. Living wills, advance directives and durable power of attorney
21.Effective interpersonal and communication skills with patients, family members, and other
health care providers
In preparation for roles as consultants to other specialists, the subspecialty trainee in CCM will frequently have the opportunity to provide consultation under the direction of faculty responsible for teaching in the CCM program.
Trainees in CCM gain experience in the administration of an ICU through the daily management of the activities in the ICU, establishment of policies regulating functioning of the ICU, and coordination of the activities of the ICU with other in-hospital units. They are invited to sit on hospital committees that make policies affecting the ICU.
Subspecialty conferences, including mortality and morbidity conferences, journal reviews and
research seminars, are regularly scheduled. Trainees in CCM take an active role in the planning and production of these conferences. Attendance at multidisciplinary conferences is encouraged, with particular attention given to those conferences relevant to CCM.
CCM residents are encouraged to participate in any of the research projects active in the ICU. They are also encouraged to initiate projects on their own. Faculty offer extensive experience in
study design, biostatistics, grant funding and protocol writing, and manuscript preparation to assist them.
• At monthly staff meetings, and with the quarterly evaluations, the knowledge, skills, and professional growth of each resident in the program is evaluated, using appropriate criteria and procedures.
• Evaluations are communicated to the resident in a timely manner;
• Quarterly evaluations, signed by the resident, are submitted to the GME Office for the institutional record.
• A permanent record of evaluation for each resident, which is accessible to the resident and other authorized personnel, is maintained by the program.
• A written final evaluation for each resident who completes the program is submitted to the GME Office for the institutional record.
• We participate in the Society of Critical Care Medicine's annual written exam process (MCCKAP).
• The program adheres to fair procedures that are consistent with The George Washington University Medical Center policies regarding academic discipline and resident complaints or grievances.
• The program director and teaching staff consistently monitor resident stress, including mental or emotional conditions inhibiting performance or learning, and drug or alcohol related dysfunction. Timely provision of confidential counseling and psychological support services to residents is provided. Training situations, which are found to consistently produce undesirable stress on residents, are evaluated and modified.