The broad goals and objectives of the Surgical Critical Care Fellowship program at Duke University are summarized below. More specific, unit-based objectives are detailed in the program handbook.
Fellows will provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Fellows will gain competence in a number of procedures, diagnostic tests, and skills that are utilized in a state-of-the-art surgical intensive care unit.
At the completion of the fellowship, fellows will demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences, as well as the application of this knowledge to patient care.
Practice-based Learning and Improvement
Fellows are expected to develop skills and habits that enable them to: systematically analyze clinical practice using quality improvement methods and implement changes with the goal of practice improvement; locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems; undertake investigations into the various areas of surgical critical care, such as new instrumentation, identification of important physiologic parameters, evaluation of pharmacologic agents in critically ill patients, or health outcomes and/or health policy issues related to surgical critical care.
Interpersonal and Communication Skills
In addition to the broad, competency-based goals and objectives outlined in the handbook, there are specific, unit- or rotation-based goals and objectives that the Surgical Critical Care fellow should achieve during that specific rotation. The majority of the fellow’s time during the year is spent at the Duke University Hospital SICU. The other required rotations, in the Medical Intensive Care Unit and the Neuroscience Intensive Care Unit, serve to complement the fellow’s experience in the SICU and to further enhance the acquisition of knowledge and technical skills. Two months of elective rotations are allowable and give the fellow the opportunity to concentrate on specific areas of critical care of particular interest to the fellow. Since it is not possible for the fellow to experience every possible elective rotation, any weaknesses or deficiencies in the fellow’s experience in some aspects of critical care necessarily have to be covered by other means, including Grand Rounds, didactic teaching sessions, board review sessions, completion of online training modules or self-directed learning.
The rotations through the SICU are characterized by progressive knowledge acquisition and progressive responsibility during the course of the year. The first three months should be spent acquiring essential critical care procedural skills under direct supervision of the attending intensivist and assimilating core medical knowledge relevant to the practice of surgical critical care. Skills to be mastered during this timeframe include placement of central lines and PA catheters, bronchoscopy, placement of arterial lines and chest tubes, airway and ventilator management, radiograph interpretation, and resuscitation management. Core medical knowledge during the first three months can be obtained by attending conferences, Grand Rounds, daily rounds, twice weekly didactic sessions, and completing the online training modules, which currently include thirteen presentations covering the following core topics: gas exchange; ventilator modes; ventilator weaning; overview of shock; septic shock pathophysiology; septic shock treatment; ARDS pathophysiology; ARDS treatment; Invasive monitoring I; Invasive monitoring II; metabolic basis and assessment of nutrition; evidence-based medicine approach to nutrition; and total parenteral nutrition. During the first three months of the year, the fellow is expected to actively participate in daily rounds, but not necessarily lead them.
The next six months of the year may be spent in a number of different rotations, including the SICU. The fellow should have attained the self-confidence by this time to be able to teach procedures and skills he/she has mastered to housestaff and medical students. The fellow should take an active role in didactic and evidence-based teaching of junior housestaff and students. The fellow should be able to critically analyze pertinent literature and start to develop a practice pattern that is fundamentally sound, evidence-based, and effective.
The final three months of the year should witness the transformation of the fellow into a team leader and master of surgical critical care. The fellow should lead rounds, under the supervision of the attending intensivist, formulate patient care plans, and obtain advanced knowledge in critical care. By the end of the year, the fellow is expected to have demonstrated sufficient competence to enter practice as a surgical intensivist without direct supervision.
During the SICU rotations, the fellow will have the opportunity to attend ICU administrative meetings at which the planning, staffing, and administrative aspects of ICU management, including ICU finance, are considered. This will fulfill the requirements of the fellow to gain experience in the administration of an ICU.
The fellow is expected to conduct scholarly research or implement a quality improvement project in the SICU. Scholarly activity may include retrospective database type research, prospective clinical studies, or writing review articles or book chapters. There is time when the fellow is on the SICU rotations to participate in these scholarly activities.
During the SICU rotations, the fellow is expected to achieve competence in the performance and application of the following critical care skills:
a) Respiratory: airway management, including intubations, bronchoscopy and management of respiratory systems;
b) Circulatory: invasive and noninvasive monitoring techniques, application of transvenous pacemakers, computations of cardiac output and of systemic and pulmonary vascular resistance, and monitoring of electrocardiograms.
c) Renal: the evaluation of renal function; peritoneal dialysis and hemofiltration; knowledge of the indications and complications of hemodialysis;
d) Gastrointestinal: utilization of gastrointestinal intubation and endoscopic techniques in the management of the critically ill patient; application of enteral feedings; management of stomas, fistulas, and percutaneous catheter devices;
e) Hematologic: assessment of coagulation status; appropriate use of component therapy;
f) Infectious disease: classification of infections and application of isolation techniques, pharmacokinetics, drug interactions, and management of antibiotic therapy during organ failure; nosocomial infections;
g) Nutritional: application of parenteral and enteral nutrition; monitoring and assessing metabolism and nutrition;
h) Monitoring/bioengineering: use and calibration of transducers, amplifiers, and recorders;
i) Miscellaneous: use of special beds for specific injuries; use of traction and fixation devices; indications for applications of hyperbaric oxygen therapy.
In addition, the fellow must acquire advanced knowledge of the following aspects of critical care, particularly as they relate to the management of patients with hemodynamic instability, multiple organ failure, and complex coexisting medical problems:
a) cardiorespiratory resuscitation;
b) physiology, pathophysiology, diagnosis, and therapy of disorders of the cardiovascular, respiratory, gastrointestinal, genitourinary, neurological, endocrine, musculoskeletal, and immune systems, as well as of infectious diseases;
c) metabolic, nutritional, and endocrine effects of critical illness;
d) hematologic and coagulation disorders;
e) critical obstetric and gynecologic disorders;
f) trauma, thermal, electrical, and radiation injuries;
g) inhalation and immersion injuries;
h) monitoring and medical instrumentation;
i) pharmacokinetics and dynamics of drug metabolism and excretion in critical illness;
j) ethical, economic and legal aspects of surgical critical care;
k) principles and techniques of administration and management;
l) biostatistics and experimental design.
The Neuroscience ICU is a 36-bed unit that cares for patients with critical neurologic problems, traumatic brain and spinal cord injury, and post-operative neurosurgical patients. Over the course of the 3-4 week rotation, the Surgical Critical Care Fellow will be expected to: perform complete neurological examinations; learn the indications for and techniques of monitoring intracranial pressure; describe the interventions for the treatment of elevated intracranial pressure; be acquainted with the technique of parenchymal tissue oxygenation monitoring and interpretation; be acquainted with the basic interpretation of EEG monitoring; learn the indications for and technique of hypothermia for traumatic brain injuries and/or cardiac arrest; gain experience in reading / interpreting brain CT scans; understand the concepts of cerebral perfusion pressure and cerebral blood flow and their clinical applications; gain a basic understanding of transcranial Doppler ultrasonography and its ICU applications; and describe the diagnosis, complications, and management of subarachnoid hemorrhage, ischemic stroke, hemorrhagic stroke, and severe traumatic brain injury.
The Medical ICU is a 32-bed unit that cares for patients with acute, critical medical problems. Frequently, these patients have multiple comorbidities, such as chronic lung or cardiovascular disease that makes their care complex and non-surgically oriented. Over the course of the 4 week rotation, the fellow will be expected to: assimilate effectively and productively into the MICU care team; gain advanced knowledge in ventilator modes and weaning from mechanical ventilation; manage acute on chronic respiratory failure; manage patients with multiple system organ failure; manage patients with hematologic crises; manage patients with heart failure; gain advanced knowledge in infectious diseases and immune deficiency disorders; and gain experience in the management of patients with inhalation injury and carbon monoxide toxicity.
The Durham VA Medical Center is situated directly across the street from Duke University Hospital. Many of the faculty at Duke also staff the VA Medical Center, which serves veterans in central and eastern North Carolina. The SICU takes care of veterans that have undergone general surgery, vascular, urologic, thoracic, cardiac, neurosurgical, and otolaryngological procedures who require critical care. The objectives of this rotation, therefore, are very similar to those of the Duke SICU rotation, outlined above. In addition, the fellow will obtain experience caring for post-operative cardiothoracic patients, including the use of intra-aortic balloon pump, pacemakers, etc. The fellow also has the opportunity to perform and interpret, under the direct supervision of the attending anesthesiologist, intraoperative transesophageal echocardiography on coronary bypass patients.
The cardiothoracic ICU is a 32-bed unit that cares for patients undergoing cardiac or thoracic surgical procedures. This includes patients undergoing coronary artery bypass grafting, minimally invasive cardiac surgery, adult congenital heart surgery, valvular heart surgery, electrophysiologic surgery, pulmonary transplantation, cardiac transplantation, implantation of advanced artificial cardiac support devices, and thoracic surgery. The fellow rotating through the cardiothoracic ICU will gain familiarity and experience in the pre-operative and post-operative management of these patients, hemodynamic resuscitation, use of intra-aortic balloon pump and other cardiac assist devices, use of inhaled nitric oxide, use of pacemakers, use and interpretation of thromboelastography, and advanced hemodynamic monitoring techniques, including non-invasive cardiac output monitoring.
The Center for Hyperbaric Medicine contains a seven-chamber complex that simulates environments ranging from an altitude of 47,000 m to a depth of 1100 m of sea water. Hyperbaric oxygen therapy is utilized to treat conditions such as decompression sickness, air embolism, carbon monoxide poisoning, necrotizing soft tissue infections, refractory osteomyelitis, threatened flaps, radiation necrosis, and selected ischemic problem wounds. The fellow rotating through the hyperbaric chamber will be trained in the clinical use of hyperbaric oxygen therapy, including treatment of clostridial myonecrosis, necrotizing fasciitis, arterial gas embolism, decompression sickness, carbon monoxide poisoning, and less common conditions, such as acute vasculitis with ischemia. The appropriate critical care monitoring and interventions will include hemodynamic monitoring, ventilator support, fluid resuscitation, and interpretation of arterial blood gases during hyperbaric oxygen treatment. The fellow will be expected to attend and participate in rounds and hyperbaric medicine conferences while on this rotation.
The fellow may opt to spend an elective rotation in Anesthesiology in the Duke Hospital Operating Room. During this rotation, the fellow works under the direct supervision of an attending anesthesiologist. The goals and objectives of this rotation include: pre-operative assessment of the surgical patient; acquisition of experience and proficiency in airway management, including routine and non-routine intubations; obtaining experience in the use of videoscopic laryngoscopy, bronchoscopic intubation, and laryngeal mask airway; development of a familiarity with the use and complications of intravenous and inhalational anesthetic agents and sedatives; obtaining experience in crisis management and hemodynamic resuscitation; and obtaining experience in the management of post-operative pain, including the dosing and troubleshooting of epidural catheters. The fellow will also gain experience in advanced monitoring techniques, use and calibration of transducers and other anesthetic equipment, and operation and troubleshooting of medical equipment. The fellow may also have the opportunity to acquire experience in the techniques of autotransfusion, cardiopulmonary bypass, transesophageal echocardiography, and cardiac assist devices.
Duke University Hospital houses a 16-bed Pediatric Intensive Care Unit with an adjoining 13-bed Pediatric Cardiothoracic Intensive Care Unit. The fellow rotating through the PICU will develop experience caring for pediatric patients with congenital heart disease, respiratory failure, immunodeficiency disorders, sepsis, hematologic and oncologic emergencies, multiorgan system dysfunction, and pediatric surgical emergencies. The fellow will participate in the care of post-operative pediatric patients that have undergone cardiovascular surgery, neurosurgery, stem cell transplant, and general surgery procedures. The fellow will be an integral part of the PICU care team, attending and participating in patient rounds and conferences. The fellow will also gain experience and develop proficiency in advanced treatment modalities for the pediatric patient, including extracorporeal life support, high frequency ventilation, nitric oxide therapy, non-invasive ventilation, cardiac assist devices, and continuous hemofiltration. The fellow will develop a familiarity with pediatric resuscitation and drug dosing, as well as with family counseling and support.
The neonatal ICU is a 38-bed unit that provides comprehensive care for premature and full-term infants with a variety of complex neonatal problems. This specialized unit is a major referral center for term infants with respiratory failure, perinatal pulmonary hypertension, and perinatal asphyxia. The fellow rotating through this unit will gain experience with delivery room resuscitation, ventilator management of the neonate, intensive care of neonates, use of high frequency ventilation, use of nitric oxide, use of extracorporeal membrane oxygenation, and management of complex neonatal surgical patients with disorders such as congenital diaphragmatic hernia. The fellow will be expected to actively participate on patient rounds and attend neonatal ICU conferences.
The coronary care unit is a 24-bed intensive care unit caring for patients with a wide variety of acute and chronic cardiovascular conditions. The fellow rotating through this unit will gain experience in the state-of-the- art, evidence-based prevention, evaluation, and management of patients with: acute myocardial infarction; unstable angina; serious cardiac arrhythmias; acute pulmonary edema; severe congestive heart failure; pulmonary embolism; pericardial tamponade; and aortic dissection. The fellow will gain experience and familiarity with the use of pacemakers, hemodynamic monitoring, and cardiac assist devices, including intra-aortic balloon pump. The fellow will actively participate in patient rounds and management and attend CCU didactic lectures and conferences.
A two-week rotation at Duke University Hospital on the Palliative Care Medicine service is available to the SCC fellow as an elective. The objectives of this rotation are to obtain a comprehensive medical history and physical exam with emphasis on communication with the patient/family about end-of-life issues; assess prognosis as appropriate; develop a basic treatment plan for patients with common symptoms associated with life-limiting illnesses, such as pain, nausea, dyspnea, delirium; demonstrate use of the interdisciplinary approach to develop a care plan; describe the use of opioid and non-opioid pharmacologic and non-pharmacologic approaches to the management of pain; describe pharmacologic and non-pharmacologic approaches to the management of common non-pain symptoms; initiate informed, relationship-centered dialogues about care; demonstrate respect for patients, families, palliative care staff and other clinicians; practice evidence-based medicine when treating palliative care patients.
Fellows must be able to demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals. Fellows, upon completion of the training program, will also be expected to teach the specialty of surgical critical care.
Fellows will demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles.
Fellows will demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. At the completion of the training program, fellows will be expected to have the skills to administer a surgical critical care unit, supervise specialized personnel, establish policy and procedures for the unit, and coordinate the activities of the unit with other administrative units within the hospital.