Critical Care Medicine Fellowship

The Critical Care faculty has dedicated time to providing direct patient care in the Intensive Care units and will directly supervise the fellows. The main teaching rounds are the multidisciplinary ICU rounds. These occur once daily, seven days a week, and last about an hour each. Multidisciplinary rounds include MDs (faculty, fellows, residents), APPs, bedside nurses, pharmacists, respiratory therapists, case managers, social workers and chaplains. These are patient-centered rounds with opportunities to discuss patient management and are opportunities for learning and teaching bedside medicine.

Multidisciplinary daily rounds in the ICU are the backbone of CCM fellowship. It will require fellows to present patients concisely and pertinently to a team of nurses, pharmacists, dieticians, respiratory therapists, chaplains, social workers, and case managers. They must outline relevant issues to direct these colleagues in providing their expertise to optimize patient care. With their unwavering support and guidance, the supervising faculty will model these presentations using a communication template and offer feedback, instilling confidence in the fellows.

The complexity of patient problems in the ICU also requires effective communication with multiple consultants. Fellows will be asked to formulate specific questions when requesting consultation from a subspecialist and are expected to discuss and coordinate recommendations. Effective communication of diagnoses, management and prognosis in terms that patients and families can understand in the stressful environment of the ICU will be modeled by the supervising faculty and evaluated by direct observation of the fellow. Discussions of end-of-life care and goals of care are expected skills for fellows to develop during the MICU rotation. Communication expertise will be developed by increasing participation in family meetings with the expectation that the fellow can direct such discussions independently by the end of their training.

The twice-weekly scheduled didactic program is based on the core knowledge content and areas defined as a fellow’s outcome in the specialty. It follows the following curriculum. It provides fellows with a Socratic approach to education. Conferences are presented by faculty and visiting professors.

Pulmonary Disease

1. Embolism, hemoptysis, and pleural disease
2. Airway Management, Asthma, and COPD
3. Acute Respiratory Distress Syndrome I
4. Acute Respiratory Distress Syndrome II
5. Mechanical Ventilation I
6. Mechanical Ventilation II

Cardiovascular Disease

1. Hemodynamics, Monitoring, Blood Flow, and Resuscitation I
2. Hemodynamics, Monitoring, Blood Flow, and Resuscitation II
3. Myocarditis, Pericarditis, Valvular, and vascular disease
4. Extracorporeal Membrane Oxygenation (ECMO): Getting the basics right
5. Extracorporeal Membrane Oxygenation (ECMO): Troubleshooting

Renal, Endocrine and Metabolic Disorders

1. Acute Kidney Injury
2. Endocrine Emergencies I
3. Endocrine Emergencies II
4. Acid-Base Critical Care
5. Electrolyte Disorders and Complications

Infectious Diseases

1. Intra-Abdominal Infections
2. Immunocompromised Host, Host Resistance, and Epidemiology
3. Infection Control
4. Pulmonary Bacterial and Fungal Infection
5. Systemic Fungal and Cardiovascular Infections

Neurological Disorders

1. Cerebral Vascular Disease
2. SCI, Coma, Post-Arrest Hypothermia

Surgery, Trauma and Transplantation

1. Surgery: Trauma, Cardiovascular, GI, and OB
2. Surgery: Environmental, General Post-op, and Transplantation

Gastrointestinal Disorders

1. Gastrointestinal Disorders

Hematologic and Oncologic Disorders

1. Hematologic/Oncological Disorders

Pharmacology and Toxicology

1. Pharmacology and Toxicology

Critical Care Ultrasound Scanning

1. Critical Care Ultrasound Scanning: Knobology
2. Critical Care Ultrasound Scanning: Basic Cardiac Views and Interpretation of LV Function
3. Critical Care Ultrasound Scanning: Thoracic US

Research, Administration and Ethics

The Morbidity and Mortality Conference is a key teaching conference during which residents and fellows present complications and discuss them with faculty. The complications are discussed with an emphasis on the current literature and are designed to promote an educational discussion.

Journal Club is held every other month and centers on presenting new clinical and scientific information. Fellows present the articles each month, and faculty assist in discussing them.

Grand Rounds are designed to keep fellows and other healthcare professionals up-to-date of new knowledge, procedures, and patient care issues.

Clinical Case Conference is a monthly fellow-led, faculty assisted conference presenting a unique case in critical care medicine and up-to-date literature on management of such case.

• CVICU: Fellows are assigned to this rotation for 3 blocks in each year of training and can choose additional elective time. The CVICU is a 36-bed unit staffed at all times by Critical Care faculty from the Department of Anesthesiology. This rotation provides exposure to the evaluation and management of a variety of patients with cardiovascular surgery, heart and lung transplant, mechanical assist devices, and other critical illnesses. In addition, the fellow will gain significant experience with ECMO and innovative cardiovascular surgical procedures.  Fellows are involved in presenting at Journal Club and case presentations in addition to didactic lectures based on ICU topics.
• MICU: Fellows are assigned to this rotation for 2 months in each year of training and can choose additional elective time. The MICU at Houston Methodist Hospital is a 24-bed unit staffed at all time by Critical Care and Pulmonary/Critical Care faculty and nurse practitioners.  Internal Medicine and prelim-residents and medical students rotate through the unit in addition to fellows. Patients present with a wide variety of conditions including sepsis, respiratory failure, pre- and post- lung transplant illness, acute and chronic renal failure, neuromuscular disease, hyperglycemic crises, malignancies and others. Fellows are responsible for direct patient care as well as supervision of residents and medical students. Procedures include endotracheal intubation, central venous lines (including hemodialysis catheters), arterial lines, bronchoscopy, paracentesis, percutaneous tracheostomy, and others. Multidisciplinary rounds are held each morning with a team that includes pharmacists, respiratory therapists, chaplains, dieticians, nurses and bioethics representatives.
• CICU: Fellows are assigned to this rotation for 1 block in each year of training and can choose additional elective time. The CICU is a 32-bed unit staffed by Critical Care and Heart Failure faculty from the Department of Cardiology. This rotation provides exposures to the evaluation and management of a variety of patients with cardiovascular issues such as heart failure, myocardial infarction, atrial and ventricular arrhythmias, pre-heart transplant, mechanical circulatory support, and mixed shock. In addition, fellows will insert pulmonary arterial catheters and perform other crucial critical care related procedures. Fellows will rotate with the "Blue" academic team, and the "Red" non-academic team.
• NICU: Fellows are assigned to this rotation for 1 block in each year of training and can choose additional elective time. The NICU is a 36-bed unit staffed by Critical Care faculty from the Department of Anesthesiology. The NICU serves patients with diseases and conditions of the brain, spinal cord, and nerves. Fellows have significant exposure to neurosurgical procedures, neuromonitoring, acute stroke, intracranial hemorrhage, innovative interventional neuroradiology procedures, brain death and organ donation.
• SLICU: Fellows are assigned to this rotation for 1 block in each year of training and can choose additional elective time. The SLICU is a 34-bed unit staffed by Critical Care faculty from the Department of Surgery and nurse practitioners. The SLICU serves a diverse group of patients including critically ill general, vascular, oncologic, transplant, orthopedic, plastic, urologic, and head and neck surgical patients. The rotation includes significant exposure to patients with decompensated liver disease as well as pre- and post- liver transplant patients.
• Virtual ICU: Fellows are assigned to this rotation for 1 block in each year of training and can choose additional elective time. The Houston Methodist Virtual ICU supports multiple satellite institutions and provides virtual critical care support. Fellows will work with Virtual ICU attendings to monitor the vitals and activity of multiple ICU's spread across the Houston Methodist Hospital System.
• ECMO: Fellows are assigned to this rotation for 1 block in each year of training and can choose additional elective time. The ECMO rotation will familiarize fellows with ECMO management, from patient selection to cannulation at bedside or the OR, day-to-day management and troubleshooting, and de-cannulation. Patients will work directly with an ECMO certified faculty member as well as the Cardiothoracic Surgery service.
• Critical Care Recovery Clinic: Fellows are assigned to this rotation for 1 block in each year of training and can choose additional elective time. The CCRC will allow fellows to follow patients that have been discharged from a lengthy ICU stay and support their recovery in an outpatient setting. They will be involved in activities such as tracheostomy management, medication list adjustments, assessment of physical and mental health, and more.

Elective Rotations

• Research: Fellows will take this block to work on academic output, including case reports, series, retrospective studies, meta-analysis and systematic reviews. Other options include being involved in CMPI committees and quality improvement projects system wide.
• Procedures: Fellows will take this block to rotate around the hospital performing procedures such as hemodialysis catheter placement, central line, arterial line, intubation, bronchoscopy (diagnostic and therapeutic), thoracentesis, chest tube insertion, indwelling pleural catheter placement, percutaneous tracheostomy, ECMO cannulation as appropriate.
• Interventional Pulmonology: Fellows will participate in evaluating patients and performing advanced bronchoscopic techniques (EBUS, navigational bronchoscopy, rigid bronchoscopy, central airway obstruction stenting, tumor coring, laser therapy, cryotherapy, APC therapy) under the supervision of a board-certified interventional pulmonologist.
• Anesthesia: Fellows will rotate through the OR's and endoscopy suites with the anesthesiologists, performing intubations with direct and video laryngoscopes.
• Other: Throughout the fellowship, fellows are welcome to approach leadership to create new rotations in critical care topics they are interested in.

Procedural competence will be assessed using a competency-based approach throughout the Critical Care Medicine program. For each procedure, progressive levels of competence will be defined, and the fellow will be assessed for levels of competency or proficiency at each level by his/her attending physicians. At each level, a decision will be made whether the fellow is competent to proceed to the next level of procedural difficulty/complexity. During each clinical rotation that involves procedural skills, the supervising attending must document a formal assessment of procedural skills for each relevant procedure. Compliance with requirements for procedure competency will be reviewed at the fellow’s semi-annual and annual reviews with the Program Director.

The fellow must maintain a log of all required and essential procedures performed in the procedure logger located in New Innovations, the residency management software system; the supervising faculty must select the level of skill observed in the procedure (i.e., the level of “mastery”), including but not limited to:

• Central lines via jugular, subclavian, and venous routes
• Arterial line via radial, femoral, and axillary routes
• Chest tubes (both pigtail and large bores)]
• Intubations, including difficult airways
• Emergent tracheostomy
• Bronchoscopy
• Thoracentesis
• Paracentesis
• Lumbar Puncture
• ECMO cannulation and management
• Bedside POCUS and FOCUS

For assessing procedural competence, the program has developed a series of steps for developing procedural competency. The fellow is expected to complete these steps to achieve procedural competence. The process includes:

1. The fellow will receive an introduction to the basic skills and concepts of each procedure; this will occur initially at the beginning of each rotation for specific procedures to be performed or as part of a scheduled educational session.
2. The fellow will receive procedural training in sedation knowledge and skills and some critical care procedures in the Methodist Institute for Training, Innovation, and Education (MITIE) simulation laboratory, the Methodist Bronchoscopy Unit, and the MICU.]
3. Throughout the two years of fellowship training, the fellow will observe the attending faculty physician(s) or other certified healthcare provider(s) perform the procedure on the clinical rotations.
4. The fellow will demonstrate all procedural skills under the supervision of the attending faculty physician.
5. Regardless of the fellow’s level of skills in performing procedures, all procedures must be performed under the supervision of a faculty physician authorized (i.e., credentialed) to perform these skills by Houston Methodist Hospital except in life-threatening emergencies (i.e., need for intubation). In emergencies, a fellow may perform a procedure in which they have demonstrated competency pending the arrival of the attending faculty.

The faculty will monitor fellow performance and learning on an ongoing basis. Fellows will always be under the supervision of the attending faculty. That means the fellows are monitored during rounds, consults, and procedures. There will be close working relationships and interactions with faculty and program staff. All academic resources available via the program, GME office, and the Hospital, such as library access, grand rounds, journal clubs, symposiums, training on scientific writing, and IRB applications, will be offered. Fellows receive instruction about the institutional resources of the Hospital and the GME Office during orientation and are encouraged to use these resources.