Clinical Training | Section of Acute and Critical Care Surgery

Nine months of the 12-month fellowship period are reserved for ICU training. Fellows divide their clinical ICU training months among several intensive care units, including the Surgery/Burn/Trauma Intensive Care Unit (SICU), Cardiothoracic ICU, and Parkview Tower ICU, Christian Hospital Northeast ICU, with optional elective time in the Neurology and Neurosurgery ICU, Medical ICU, Coronary Care Unit and Pediatric ICU. Additional rotations are available in airway/anesthesiology, trauma surgery, critical care ultrasonography, nutrition support, Tele ICU, ECMO/advanced mechanical ventilation, renal medicine, infectious diseases, radiology and cardiac echography.

Fellows will also spend time on the trauma service, and take overnight call on this rotation. They are primarily responsible for overseeing the chief residents, responding to trauma activations, and operating on trauma and emergency general surgery patients. In addition, the Surgical Critical Care Fellows will have the opportunity to participate in operative cadaver labs.

Clinical Training Environment

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

Fellows benefit from the expertise of outstanding critical care faculty, and they perform their medical duties in facilities that are among the most advanced in the country. There are 183 critical care beds, and the critical care units are equipped with leading-edge technology and are designed to accommodate innovative treatment approaches. Washington University is known for its highly collaborative and interdisciplinary approach to patient care. This atmosphere enriches the training experience by exposing fellows to the many facets of medicine. Washington University also hosts C-STARS (Centers for the Sustainment of Trauma and Readiness Skills) faculty and nurses who work closely with our fellows across multiple critical care specialties.

Clinical Fellow Training Opportunities

Surgery/Burn/Trauma Intensive Care Unit (SICU): This 36-bed unit is an advanced facility that was completed in October 2012 and receives more than 1,600 admissions each year. It is the primary training base for surgical critical care fellows. The unit serves general surgical patients and patients from all the surgical specialties. Washington University Medical Center is a Level 1 trauma center and a regional burn center and the SICU serves many trauma and burn patients. Fellows also treat patients who have had vascular, transplant, hepatobiliary, endocrine/oncology, ENT and orthopedic surgical procedures.
Parkview Tower ICU (PVT): There are 12 ICU beds in the Parkview ICU with colorectal, urology, minimally invasive surgery, OB/gyn, oncology and medicine patients that fellows will rotate thru as well. In addition, the fellows attend rapid response calls and codes with the APPs while on rotation in the PVT ICU.
Cardiothoracic Intensive Care Units: Fellows assist in the management of the complex pathophysiology associated with cases in these units which house 36 beds, which serve all cardiac and thoracic surgical patients at Barnes-Jewish Hospital. In addition to a large general cardiac and thoracic caseload, Washington University has the world’s largest lung transplantation program and an active cardiac transplantation program. Fellows will receive exposure to extracorporeal oxygenation (ECMO) systems, left ventricular assist devices (LVADs) and intra-arterial balloon pumps, in addition to other mechanical support devices.
Acute and Critical Care Surgery: Fellows will spend 2 rotations on the ACCS service, where they are primarily responding to trauma activations, rounding and operating on patients with traumatic injuries. Fellows will also take call throughout the rotation, where they will have exposure to emergency general surgery patients, in addition to the traumatically injured patients. There is a high operative volume on our ACCS service.
Neurology and Neurosurgery Intensive Care Unit: This 29-bed unit serves more than 1,000 patients a year. Fellows learn to manage a wide variety of primary brain and spinal cord insults.
Medical Intensive Care Units: There are 2 medical intensive care units, with 34 ICU beds, that are the primary intensive care units for critically ill patients from all medical subspecialties. Fellows are directly involved in the management of all patients and have ample opportunity to learn diagnostic procedures and therapeutic interventions.
Coronary Care Unit: This 15-bed unit is the primary intensive care unit for critically ill patients with acute myocardial disease. Fellows gain extensive exposure to noninvasive diagnostic techniques and interventional cardiology.
Pediatric Intensive Care Unit: There are 52 beds encompassing a wide range of cardiac and non-cardiac congenital and acquired pathophysiology cases in the pediatric population. Fellows study the pathophysiology of medical and surgical critical illness in infants and children; learn diagnostic skills and therapeutic procedures; and participate in rounds, didactic presentations, on-call status and teaching of residents and medical students
Christian Northeast Hospital: This 26 bed mixed cardiac, medical and surgical ICU serves a community ICU experience for the fellows. The fellow will have exposure to a wide variety of critically ill patients, in addition to initial evaluation, management and triage of those critically ill patients requiring transfer to the ICU.

Clinical Training Educational Objectives

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

Surgical ICU (4400 &7800 ICU) — Upon completion of the multiple rotations the fellow will spend in this ICU, it is expected the fellow will have exposure to and develop clinical expertise in: airway maintenance and management, mechanical ventilation and devices that supply supplemental oxygen, indications of and techniques for emergency and therapeutic treatment of conditions requiring thoracentesis and/or tube thoracotomy, emergency and therapeutic fiberoptic laryngotracheobronchoscopy, assessment and evaluation of pulmonary function, cardiopulmonary resuscitation, placement and management of arterial, central venous and pulmonary arterial catheters, computations of cardiac output and of systemic and pulmonary vascular resistance, monitoring electrocardiograms, pharmacologic and mechanical support of circulation, evaluation of central nervous system dysfunction, use of intracranial pressure monitoring techniques, recognition and treatment of hepatic and renal dysfunction, knowledge of the indications and complications of hemodialysis, diagnosis and treatment of sepsis, fluid resuscitation and management of massive blood loss, enteral and total parenteral nutrition, utilization of gastrointestinal intubation and endoscopic techniques in the management of the critically ill patient, management of stomas, fistulas and percutaneous catheter devices, application of autotransfusion, assessment of coagulation status, appropriate use of component therapy, bioengineering and monitoring including use and calibration of transducers, amplifiers and recorders, interpretation of relevant laboratory results, psychiatric effects of critical illness, ethical and legal aspects of critical care, critical obstetric and gynecologic disorders, trauma, thermal, electrical and radiation injuries, inhalation and immersion injuries, pharmacokinetics and dynamics of drug metabolism and excretion in critical illness, classification of infections and application of isolation techniques, drug interactions and management of antibiotic therapy during organ failure, nosocomial infections, principles and techniques of administration and management, use of special beds for specific injuries, traction, and fixation devices, and biostatistics and experimental design.
Cardiothoracic ICU (5600 &8300ICU) — Upon completion of this rotation, it is expected the fellow will have exposure to and develop clinical expertise in indications of and techniques for emergency and therapeutic treatment of conditions requiring thoracentesis and/or tube thoracotomy, cardiopulmonary resuscitation, central venous and pulmonary arterial catheters, emergency and therapeutic placement of pacemakers, computations of cardiac output and of systemic and pulmonary vascular resistance, monitoring electrocardiograms, management of cardiac assist devices, pharmacologic and mechanical support of circulation, fluid resuscitation and management of massive blood loss, bioengineering and monitoring, interpretation of relevant laboratory results, and transesophageal echocardiography (TEE).
Medical ICU (8300 & 8400 ICU) — Upon completion of this rotation, it is expected the fellow will have exposure to and develop clinical expertise in mechanical ventilation and devices that supply supplemental oxygen, assessment and evaluation of pulmonary function, cardiopulmonary resuscitation, pharmacologic and mechanical support of circulation, recognition and treatment of hepatic and dysfunction, diagnosis and treatment of sepsis, bioengineering and monitoring, interpretation of relevant laboratory results, assessment of coagulation status, and appropriate use of component therapy.
Christian Hospital Northeast ─ Upon completion of this rotation, it is expected the fellow will have exposure to and develop clinical expertise in the management of critically ill patients with medical and surgical complications in a community ICU setting. In addition, the fellow will learn to understand ICU resource limitations, understand and apply the ICU consultant model and communication in a community ICU setting.
Coronary Care Unit (8200 ICU) — Upon completion of this rotation, it is expected the fellow will have exposure to and develop clinical expertise in cardiopulmonary resuscitation, central venous and pulmonary arterial catheters, emergency and therapeutic placement of pacemakers, pharmacologic and mechanical support of circulation, interpretation of relevant laboratory results, transesophageal echocardiography (TEE), computations of cardiac output and of systemic and pulmonary vascular resistance, and monitoring electrocardiograms
Pediatric ICU — Upon completion of this rotation, it is expected the fellow will have exposure to and develop clinical expertise in critical pediatric surgical conditions, pharmacologic and mechanical support of circulation, and interpretation of relevant laboratory results.
Neurologic/Neurosurgery ICU (9400 & 10400 ICU) — Upon completion of this rotation, it is expected the fellow will have exposure to and develop clinical expertise in evaluation of central nervous system dysfunction, the performance of complete neurologic examinations, use of intracranial pressure monitoring techniques and of the electroencephalogram to evaluate cerebral function, and interpretation of relevant laboratory results.
Acute and Critical Care Surgery — Upon completion of this rotation, it is expected the fellow will have exposure to and develop clinical expertise in the operative and medical management of patients with trauma, thermal electrical, inhalation and immersion injuries, as well as fluid resuscitation and management for massive blood loss. Also the fellow will have exposure to many types of emergency surgery and hernia repairs, including NSTIs, bowel perforations, fistulas and other surgical emergencies.
Airway/Anesthesiology — Upon completion of this rotation, it is expected the fellow will have exposure to and develop clinical expertise in airway maintenance and management, emergency and therapeutic fiberoptic laryngotracheobronchoscopy.
Ultrasonography — Upon completion of this rotation, it is expected the fellow will be competent to perform basic abdominal, pulmonary, pleural, cardiac and vascular ultrasonongraphy as part of the multidisciplinary curriculum in critical care medicine.
Nutrition — Upon completion of this rotation, it is expected the fellow will have exposure to and develop clinical expertise in enteral and parenteral nutrition formulas, placing bedside feeding tubes, fluid and electrolyte management and writing TPN orders.
TeleICU — Upon completion of this rotation, the fellow will gain exposure to computer-based remote ICU care including decision support, population management tools, real-time analytics, and APACHE benchmarking methodology among multiple different patient populations in various ICU settings.
ECMO/Advanced Mechanical Ventilation — Upon completion of this rotation, it is expected the fellow will have exposure to specific issues involved in managing patients being supported by extracorporeal membrane oxygenation (ECMO). The fellow will also have exposure to an advanced review of evidence based management of invasive ventilation.
Infectious Diseases Consult — Upon completion of this rotation, it is expected the fellow will have exposure to and develop clinical expertise in interpretation of relevant laboratory and microbiological results, classification of infections and application of isolation techniques, drug interactions, and management of antibiotic therapy in nosocomial infections.
Renal Consult — Upon completion of this rotation, it is expected the fellow will have exposure to and develop clinical expertise in recognition and treatment of renal dysfunction, knowledge of the indications and complications of hemodialysis (both intermittent and continuous) as well as ultrafiltration, and interpretation of relevant laboratory results.
Transesophageal echo (TEE) — Upon completion of this rotation, it is expected the fellow will have exposure to and develop expertise in transesophageal echo. This includes computation of cardiac output and of pulmonary vascular resistance and determination of valvular and wall abnormalities.
Radiology — Upon completion of this rotation, it is expected the fellow will have exposure to and develop expertise in interpretation of computed tomography (CT) scans and chest radiographs. This should include analyzing a wide range of radiographic images, from normal studies to those with severe pathology commonly present in critically ill patients.