Pediatric Critical Care Medicine Fellowship

The overall goal of the Pediatric Critical Care Medicine Fellowship Program is to train and prepare subspecialty residents to serve as leaders in the field of pediatric critical care medicine using the six competencies set forth by the ACGME: medical knowledge; patient care; professionalism; interpersonal and communication skills; practice-based learning and improvement and systems-based practice.

Fellows rotate through the pediatric critical care service, pediatric cardiac ICU service, procedural sedation service and the pediatric palliative care service. Fellows can carve out time during the fellowship for electives within the Florida Poison Information Center Miami, located at University of Miami Leonard M. Miller School of Medicine/Jackson Memorial Hospital; trauma ICU or neonatal intensive care unit, depending on their long-term plans. Our fellows offer 24-hour, in-house coverage and are expected to respond and assist in pediatric trauma cases presenting to the Ryder Trauma Center, and respond to any pediatric emergencies on the pediatric wards.

Such training will prepare the fellows for successful academic and/or clinical careers in the field of pediatric critical care medicine. During the fellowship period, there is an expectation of increased responsibility and participation with regard to clinical duties, administrative tasks and commitment to research. The ultimate goal is to mentor the critical care trainees such that, upon completion of the program, they exhibit competence and may practice independently in the field of pediatric critical care.

This rotation, during the first year of training, allows fellows to understand the principles of airway management, while gaining a better understanding of the effects of sedation and muscle paralysis.

Fellows will learn to use a bag valve mask effectively to appropriately ventilate and oxygenate a deeply sedated or anesthetized patient, and will
learn/refine the process of endotracheal intubation in infants, children and adolescents.

This clinical rotation provides the opportunity to learn principles of: acute and convalescent post-operative care of infants and children with congenital or acquired heart disease; operative therapies; pre-operative evaluation and preparation and stabilization.

The cardiac critical care service rotation has improved since the time of the site visit. There is increased integration of the critical care medicine trainees on this service. One fellow is assigned to this service at all times. This fellow shares in all aspects of patient management which involves a tiered approach with the cardiology team; intensivist covering the cardiac service and primary cardiothoracic surgeon. Increased responsibilities are developed over the three fellowship years.

Year 1:
This initial clinical exposure is dedicated to general development of technical skills and critical assessment skills necessary for the care of the child with congenital heart disease. During this year, fellows are expected to achieve procedural competence in advanced resuscitative techniques; airway management and central venous access through direct faculty supervision and instruction. The fellows participate in the daily, multidisciplinary practice of critical care medicine. This year is devoted to achieving a broadened fund of knowledge with cardiac critical care topics. The trainees are expected to increase their confidence level in daily decision making with clinical issues. This mandates the ability to interact with a number of different subspecialties and fine-tunes the competencies of professionalism and communication skills. Fellows are intimately supervised by the service attending, yet are encouraged to participate in daily critical decision making with regard to bed utilization and patient flow.

Organization and prioritizing are specific goals over the first year. Decision- making is critiqued daily by the supervising critical care attending. Required weekly patient management conferences provide additional mentorship in decision-making, as well as alternative approaches provided by the cardiology; cardiothoracic surgical and critical care faculty.

Year 2:
The goals and objectives are the same as the first year with encouragement of more independence. The fellows have an increased expectation in determining the daily plan of care of the patients with congenital heart disease. The fellows begin to achieve an incremental increase in responsibility and independence in decision-making. At this stage, the fellows often begin teaching procedural skills to junior fellows.

Responsibility in tracking clinical patient information is expected: continuous quality improvement; maintenance of clinical and procedural database; proprietary central venous catheter patient database and morbidity and mortality presentations. Fellows begin to take a more active role in initiating patient management discussions with ancillary subspecialties.

Year 3:
The goals and objectives are the same as the first and second year with increased clinical independence. The goal for the trainee at this time is to begin to function independently as an instructor-attending physician.

The trainees are oriented to their clinical role in the PICU by the on-service critical care attending. The goals for each year of training are monitored by critical care medicine faculty. The trainee’s progress and achievement of goals is discussed at general faculty meetings. Specific areas of concern are addressed and verbal feedback is provided to the fellows, as needed.

All fellows are expected to give a thorough orientation at the beginning of the rotation to the on-service PGY-2 and 3 residents rotating through the PICU.
The fellows are expected to be present during morning rounds to assist with the explanation of overnight incidents, learn from refinements of decisions made during their call night and to facilitate the flow of the morning rounds and transition of care.

Year 1:
This initial clinical exposure is dedicated to general development of technical skills and critical assessment skills necessary for the care of the critically ill and injured child. During this year, fellows are expected to achieve procedural competence in advanced resuscitative techniques; airway management and vascular access (arterial and venous) through direct faculty supervision and instruction.

This year is devoted to achieving a broadened fund of knowledge with critical care topics. The trainees are expected to increase their confidence level in daily decision making with clinical issues. This mandates the ability to interact with a number of different subspecialties and fine-tunes the competencies of professionalism and communication skills. The fellows gain a sense of triage by providing consults to the pediatric wards, trauma and the pediatric emergency department. Fellows are intimately supervised by the service attending, yet are encouraged to participate in daily critical decision making with regard to bed utilization and patient flow. Organization and prioritizing are specific goals over the first year.

The fellows are encouraged to assume a leadership role with the didactic and clinical training of the PGY-2 and PGY-3 pediatric residents. Fellows have additional mentorship from the senior critical care fellows during transfer of patient care. Decision making is assessed daily by the supervising critical care attending and feedback is given, as needed. Required weekly patient management conferences provide additional mentorship in decision-making as well as alternative approaches provided by general faculty and senior fellows. Attendance of Pediatric Grand Rounds and Pediatric Staff Conference by the fellows is encouraged unless patient care requires their presence in the PICU.

Year 2:
The goals and objectives are the same as the first year with encouragement of more independence and emphasis on research. The fellows have an increased expectation to supervise the residents rotating in the pediatric critical care unit. The fellows begin to achieve an incremental increase in responsibility and independence in decision making. At this stage, the fellows often begin teaching procedural skills to junior fellows and residents. Responsibility in tracking clinical patient information is expected: maintenance of clinical and procedural data bases; a central venous catheter patient database; continuous quality improvement as well as morbidity and mortality presentations. Fellows begin to take a more active role in initiating patient management discussions with ancillary subspecialties. The fellows usually have selected a specific research interest to pursue by this time. This year affords more time for targeted research and expanding a specific area of investigative interest.

Year 3:

The goals and objectives are the same as the first and second year with increased clinical independence and a predominance of time spent in research. The goal for the trainee at this time is to begin to function independently as an instructor-attending physician. The majority of time is focused upon finalizing research interests. Fellows are guided in selecting a career. At this stage, the attending hopes to provide finalizing mentorship and ensure that all sub-specialty requirements have been achieved.

Occurring at various points throughout the fellowship, this rotation provides the trainee with an opportunity to learn and enhance skills in the provision of moderate and deep sedation. There is focused training on the assessment and management required in evaluating sedation needs for a variety of procedures, including biopsies (renal, liver, bone marrow); bronchoscopies; colonoscopies and upper endoscopies, but most focus is on radiologic sedation needs.

The fellows are exposed to administrative issues within the hospital concerning sedation policy and procedures. Fellows are directly supervised and mentored by the attending covering this service.

The trainee provides consultation to pediatric house staff with respect to sedation issues throughout the hospital. This rotation allows for the recognition of high-risk airways and encourages close collaboration with the Department of Anesthesia.
The fellows gain competence in rescuing patients from deep levels of sedation or anesthesia.

Trainees are provided with a comprehensive introduction to the process of scientific investigation. The general faculty provides mentorship at departmental research conferences. Trainees align themselves with a specific mentor corresponding with their area of interest.

Expectations of the research experience include: critique of research presentations by colleagues; data collection; design of an investigative protocol; formulation of a research hypothesis; preparation of abstract/manuscript and presentation of results at scientific sessions (onsite, regional or national meetings). Mentorship is provided with respect to review of research protocols and acquisition of funding for research.

Year 1:
Identify a potential research interest and do all of the background reading required to familiarize oneself with the topic. Obtain Collaborative Institutional Training Initiative training and certification.

Year 2:
Identify a potential research interest and organize background reading and information. Begin to formulate a research plan and present the research plan to the division and scholarly oversight committee. Develop and submit an Institutional Review Board protocol, and begin data acquisition and assessment of the data.

Year 3:
Identify a potential research interest and organize background reading and information. Begin to formulate a research plan and present the research plan to the division and scholarly oversight committee.

Obtain IRB or Institutional Animal Care and Use Committee approval for their protocol and meet with the scholarly oversight committee to present findings of research.

Complete data acquisition and begin statistical analysis. Organize data and results and complete the research project.

Prepare a manuscript or abstract and consider submission to a local or national meeting. Prepare manuscript for submission to a peer-reviewed journal.