Pulmonary Disease & Critical Care


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Pulmonary Disease & Critical Care

Medicine Fellowship
Fellow Responsibilities 2014-2015
MICU – LIJ

There will be 2 fellows that rotate in the LIJ MICU at any given time, with specific responsibilities assigned to each fellow.

MICU 1 Fellow:

1. Primary fellow responsible for all the patients in the MICU.

2. Fellow will receive sign-out at 7 am each morning and sign out to the night intensivist at 5 pm each day.

3. Supervise the residents with their responsibilities and procedures (central lines, arterial lines, etc).

4. Procedures such as intubation, percutaneous tracheostomies, and bronchoscopies are performed by the fellow and supervised by the attending physician. All procedures must be logged into the procedure book.

5. Certain procedures often require the bronchoscopy lab nurses to be present such as percutaneous tracheostomies, FEESST, and bronchoscopies. The fellow is responsible for coordinating this with the bronchoscopy lab, ext 7069, pager 06835.

6. Attend interdisciplinary rounds that occur daily at approximately 11:45 AM.

7. Daily care plans/goals: Assess the need for central lines, arterial lines, Foley catheters, PUD and DVT prophylaxis on a daily basis

8. The fellow is responsible for a majority of the "non-rounding" teaching time.  Formal lectures should be given to the residents and interns by the fellow on critical care topics.

9. MICU to MICU inter-institutional transfers are coordinated by the transfer center. Requests for transfer are to be directed to the MICU attending who will decide whether the patient is accepted.

10. It is the responsibility of the MICU 1 fellow to orient the interns & residents every Monday to the MICU (preferably about 15 minutes before rounds). A housestaff orientation manual is located on the Pulmonary fellows website (pulmfellows.homestead.com) to be printed and distributed.

MICU 2 Fellow:

1.  Evaluate all new consults during ICU rounds. Consults after rounds will first be seen by the ICU residents and then presented to the MICU 2 fellow and attending. Patients rejected from the ICU or transferred will need at least 1x follow up within 12 hours.  

2. Rapid responses and medical codes are run by the residents (MAR) but the fellow is expected to assist if needed.

3. Assist the MICU 1 fellow with procedures and emergencies.
4. Round on and be responsible throughout the day for MICU boarders located in other critical care units.
5. Check and restock the ICU Bronchoscopy cart on Monday mornings and Friday afternoons.
6. Daily ensure that the ultrasounds are present and functioning, the glidescope is present with the stylet, and the TEE probe is available and ready for use.
MICU – NS

1.  The fellow will receive sign out at 7 am from the night intensivist on all the patients. Sign out to the overnight fellow/NP each night at 6 PM.

2. There are 2 teams in the MICU – the yellow team (consisting of fellow, attending and internal medicine interns) and green team (attending, NP or PA and emergency medicine housestaff). The fellow will round on the yellow team patients every morning with the team, but is expected to assist with all emergencies and procedures in the ICU as needed.

2.  The interns are responsible for completing daily progress notes on all the patients. The fellow is responsible for prerounding with the interns, overseeing care of the patients, reviewing their daily notes and supervising all procedures.

3.  The fellow is responsible for triaging all new ICU consults throughout the day, with assistance from the Acute Critical Care Team (ACCT) as needed.

4.  Bronchoscopies, intubations and percutaneous tracheostomies are all to be done by the fellow and supervised by an attending. The MICU fellow is responsible for coordinating schedules with the pulmonary attending and the bronchoscopy lab nurses (x4592). All procedures should be logged into the ICU procedure book.

5. The fellow is responsible for a majority of the "non-rounding" teaching time and formal lectures should be given to the interns and NPs/PAs.
8. Weekends- MICU fellow is responsible for all the patients in the ICU and see consults throughout the day until 6 pm when the ACCT attending arrives.
9. MICU to MICU inter-institutional transfers are coordinated by the transfer center. Requests for transfer are to be directed to the MICU attending who will decide whether the patient is accepted.
10. Daily care plans/goals: Assess the need for central lines, arterial lines, Foley catheters, PUD and DVT prophylaxis on a daily basis.

11. It is the responsibility of the MICU fellow to orient the interns & residents every Monday to the MICU (preferably about 15 minutes before rounds). A housestaff orientation manual is located on the Pulmonary fellows website (pulmfellows.homestead.com) to be printed and distributed.

12. Daily ensure that the ultrasounds are present and functioning, the glidescope is present with the stylet
PULMONARY CONSULTATION SERVICE – LIJ

1. Responsible for receiving all new pulmonary consults for service patients (no prior pulmonologist, has a pulmonologist that does not come to LIJ, patients seen in the faculty practice or fellows clinic) between 7am and 5pm. Any consults that are deemed non-urgent from the previous night by the on call fellow will be relayed to the consult fellow by 7 am the next morning.

2. Cystic fibrosis patients - admitted to the pulmonary consult service and are covered by housestaff. The housestaff will evaluate the patient and present to the pulmonary consult or on-call fellow. The housestaff is responsible for writing the H&P, orders and for discussing the daily plan of care with the pulmonary fellow as well as any acute changes. The fellow must round on these patients daily.

4. Communicate recommendations to the primary attending and residents/NPs/PAs.

5. Written sign-out to the weekend on-call fellow. Included on the sign-out should be a list of which patients to see on which days, acute issues and plan of care. Also, there must be a clear indication of which patients are on our service (CF patients).

6. Provide the next consult fellow (at the end of the rotation) with a detailed sign out.

7. Ultimately the consult attending is responsible for all decisions related to patient care and the fellow should inform the attending immediately of any urgent issues which arise.

8. The consult fellow is primarily responsible for all conferences that involve case presentations (Monday Radiology Conference and Wednesday Management Conference). See the conference section for further detail.

9. The procedure fellow will perform all procedures on consult patients.

PULMONARY CONSULTATION SERVICE – NS

1. The fellow is responsible for receiving all new pulmonary consults (including RCU consults) between 7am and 5pm. These patients should be unattached (no prior pulmonologist), have a pulmonologist that does not come to NS, or are patients seen in the faculty practice or fellows clinic. Any consults that are deemed non-urgent by the overnight on-call fellow will be relayed to the consult fellow by 7am the next morning.

2. The fellow is responsible for rounding with the consult attending. Every patient admitted to the pulmonary service/RCU must be seen daily.

3. Communicate recommendations to the primary attending and residents/NPs/PAs.

4. The procedure fellow should be available to perform all procedures on consult patients, especially when the service is busy.

5. The consult fellow is primarily responsible for all conferences that involve case presentations (radiology conference and the Wednesday management conference). See the conference section for further detail.

6. The fellow is responsible for providing the weekend on-call attending with written sign-out every Friday afternoon.

7. Provide the next consult fellow (at the end of the rotation) with detailed written sign out of all the patients on the consult service.

8. Ultimately the consult attending is responsible for all decisions related to patient care and the fellow should inform the attending immediately of any urgent issues which arise.
9. The RCU at NS is covered by the consult fellow. The fellow is responsible to round with the RCU staff at 10 am Mon-Fri on the service patients. Private patients will not be covered by the fellow. The Bronch/procedure fellow is expected to help out with any emergencies.
10. Regarding all potential transfers to the RCU, the consult fellow must discuss each patient with the consult attending to determine if the transfer is appropriate.

11. The procedure fellow will perform all procedures on consult patients.
PULMONARY/RESPIRATORY CARE UNIT - LIJ
1. This is a 16-bed unit composed of 6 RCU beds & 10 Pulmonary beds

 

2. Fellows will round with an attending and NP/PA’s, as well as attend interdisciplinary rounds.
3. The fellow is directly involved in the coordination of care for all patients on the ward and is expected to oversee the decisions made by the NP/PA’s.
4. The attending is ultimately responsible for all decisions related to patient care and the fellow should inform the attending immediately of any urgent issues which arise.
5. There will be 2 dedicated NP/PA's during the week. The RCU NP will take care of the 6 RCU patients, including H&P's, daily notes, orders, discharge note, etc. The second NP will take care of the remaining 10 pulmonary patients, including daily notes, orders, discharge notes, etc.

 

6. The fellow is expected to triage admissions. Eligible patients include unattached patients (no private pulmonologist) or faculty practice (seen as outpatient by our attending or in the NS/LIJ clinics).
7. Admission Criteria: primary pulmonary issue, including COPD exacerbations, Asthma exacerbations, ILD, pneumonia, pulmonary HTN, and bronchiectasis exacerbations. Patients who require first time BiPAP for a pulmonary issue can be admitted to the Pulmonary unit (not for heart failure, not for patients with a private pulmonologist).
9. CF patients will not be admitted to the Pulm/RCU unit, but will continue to be admitted to 5 North and will be followed by the consult fellow and attending. 
10. Admission Process: The ED will contact the fellow for admission of a patient with a primary pulmonary issue. If the patient is unattached, seen in faculty practice or the fellows’ clinic, then the fellow either accepts or rejects the patient depending on bed availability and the case presented.
11. Fellows are responsible for completing the Admission note on weekdays from 7AM-5PM for all the pulmonary patients and the NP will complete the admission orders. Evenings and overnight (5PM-7AM), the admission will be done by hospitalist or housestaff. If a hospitalist does the H&P, then the case does not have to be reviewed with the fellow. If housestaff perform the H&P, then the fellow will get called to discuss the case and plan.
12. Signout: the fellow covering the Pulm/RCU Unit during the week will provide a written and brief verbal signout to the on-call fellow. The most important information to include is any acute issues and bed availability so that the on-call fellow can know how many patients to accept overnight.
13. For patients that remain on housestaff, the fellow is expected to round with the resident and intern daily to discuss the plan and provide case-based learning.
14. It is the fellows’ responsibility to notify the consult fellow if a patient is transferred to another floor
15. Fellows are responsible for emergencies on all patients in the Pulmonary/RCU unit. During the night, there will be an NP/PA available, but the on call fellow will be called for acute issues.

 

16. Fellows will be rounding in the Pulm/RCU Unit on Saturdays & holidays with the attending. The RCU NP will see the 6 RCU patients. The fellow & attending will divide the remaining 10 Pulmonary patients (except for the housestaff-covered patients). Usually, the fellow rounding on Saturday is the same fellow rounding during the week with some exceptions. Rounds should be done by 12 PM, after which the fellow may leave when all issues are taken care of. Admissions from Friday 5 pm through Monday 7 am will be done by the hospitalist or housestaff.

OTHER ROTATIONS
1. Required:

Sleep: total of 2 blocks for the fellowship, supervised by Dr. Greenberg

Cardiothoracic ICU: 1 block (at North Shore)

Neurosurgical ICU: 1 block (at North Shore)

Surgical ICU: 1 block (at North Shore)

These will be scheduled in advance by the chief fellows.
2. Other:

PFT’s: 2-4 weeks throughout fellowship. PFT’s are reviewed throughout the week with Dr. Talwar. Pulmonary rehab lectures are usually given during this rotation. It is expected that the fellow attend any scheduled CPET’s during this rotation (usually on Fridays) as well as spend time observing PFTs being performed. There will also be structured learning of PFTs for each class with Dr. Talwar.

ELECTIVES



1. Fellows on elective will be required to select a rotation from a list of approved electives unless the fellow will be engaged in structured research.
2. While on elective the fellow will still have on-call responsibilities and attend scheduled clinics as well as be available to cover other services (MICU, consults, bronch, etc.) as needed. It is imperative that fellows on elective carry their pagers and respond to pages between 8AM – 5 PM. They can be pulled at any time to cover fellows from required rotations in the event of illness or unforeseen events.
3. Some elective choices include:

Cardiac Care Unit/EP lab

Radiology (with Dr. Shah/Bacchus/Chusid)

Research

ENT

Allergy/Immunology Clinic (865 Northern Blvd)

Palliative Care

Thoracic Surgery

Ultrasound

Echo

Burn unit (at NUMC)
4. You must inform Jiselle Macdonald at least one month in advance about which elective you are doing and who you are working with. We need to account for your time for Medicare reimbursement and payroll purposes. You will be evaluated by the appropriate attending at the end of each elective.
5. If you would like to design your own elective, please see the program director. All electives will be chosen and preferably scheduled at the beginning of each academic year. Away electives take several months to be approved and finalize paperwork.
PROCEDURE
1. Procedures performed by the fellow include:

  1. Bronchoscopy

  2. EBUS

  3. FEESST

  4. Percutaneous tracheostomy

  5. Endotracheal Intubation

  6. Central line placement*

  7. Arterial line placement*

  8. Temporary dialysis catheter placement*

  9. Thoracentesis*

  10. Chest tube insertion

  11. Indwelling pleural catheter placement (Pleurx)

  12. Closed pleural biopsy

  13. Ultrasound guided lung biopsy

  14. Cardio-pulmonary exercise testing


2. Procedures marked with * may be performed by residents under supervision. All other procedures are always performed by the fellow.
3. The procedure fellow will be responsible for all bronchoscopies scheduled for one of our pulmonologists.
4. It is the responsibility of the fellow to perform all FEESST studies. At NS, they must coordinate these tests with the speech and swallow therapist and the FEESST attending. They must also coordinate the tests with the bronchoscopy nurses to assure sufficient scopes are available for all the studies planned for the day (sheaths are also available if there are multiple FEESST’s scheduled).
5. The fellow will also be available to assist the consult and MICU fellows with all procedures.
6. The fellow is responsible for maintaining a log of all procedures on New Innovations that they perform. This log must include initials and MR of patient, date, supervising attending, complications and indications for procedure. Every procedure listed must be logged.
7. ALL procedures MUST be supervised by an attending.
8. The procedure fellows are responsible for logging potential pathology conference cases in the Pulm Pathology folder on the shared L drive. Each month they will choose cases to be presented at pathology conference.
CALL-LIJ
1. Call officially begins at 5pm and ends at 7am. Accordingly, weekend call is from 5PM Friday to 7AM Monday.
2. LIJ Weekend call involves rounding in the MICU followed by rounding on the consult service patients with the on-call attending, including evaluation of new consults. The patients that need to be seen will be dictated by the consult team during the week. Patients that are admitted to our service that are not in the Pulmonary/RCU unit need to be seen daily (e.g., CF patients). The answering service for the faculty practice is also covered by the on-call fellow the entire weekend.
3. Pulmonary/RCU fellow will round on Saturdays & holidays with the attending, equivalent to a short call. The RCU NP will see the 6 RCU patients. The fellow & attending will divide the remaining 10 Pulmonary patients (unless some patients are housestaff-covered). Usually, the fellow rounding on Saturday is the same fellow rounding during the week with some exceptions. Rounds should be done by 12 PM, after which the fellow may leave after all issues are taken care of. Although there remains the possibility that fellows may have to continue covering Saturdays/Holidays during the 2nd half of the year, the department is working hard to add another NP so that this does not become necessary.
4. Pulmonary consults may be requested during nights and weekends. It is the responsibility of the on-call fellow to determine if the patient needs to be seen that night or if the consult can wait until morning. Detailed information needs to be requested in order to make a safe decision. When in doubt it is better to go in and see new consults. One exception to this rule is consults requested on the obstetric service. Even if these do not sound like an emergency, they must be seen as soon as possible. The fellow must discuss all urgent and OB consults with the on-call attending. If a fellow decides that a patient can be seen in the morning, he/she must discuss this with the on-call attending.
5. Starting July, the on-call fellow will also be responsible for accepting or rejecting patients to the Pulmonary/RCU Unit. After the ED evaluates a patient with a primary pulmonary issue (e.g., COPD exacerbation), the fellow will be called. If the patient is unattached or faculty practice, then the fellow either accepts or rejects depending on bed availability and the case presented. As listed above, the admission criteria to this unit include primary pulmonary issues, especially COPD exacerbation, but can also include Asthma exacerbations, ILD, pneumonia, pulmonary HTN, bronchiectasis, etc. CF patients will not be admitted to the Pulm/RCU unit, but will continue to be admitted to 5 North and will be followed by the consult fellow and attending (on weekends, will be followed by the on-call fellow rounding in the unit and on consults). Patients who require 1st time BiPAP for a pulmonary issue can be admitted to the Pulmonary unit (not for heart failure, not for patients with a private pulmonologist).
6. The on-call fellow is not responsible to complete the admission for patients admitted to the Pulmonary/RCU unit from 5PM-7AM. These admissions will be done by hospitalist or housestaff. If a hospitalist does the H&P, then the case will not be reviewed with the fellow overnight. If housestaff perform the H&P, then the fellow will get called to discuss the case and plan. The on-call fellow must inform the Pulm/RCU fellow in the morning regarding all patients admitted overnight (whether by hospitalist or housestaff).
7. For any issue that requires the fellow to return to the hospital, the on-call attending needs to be notified.
8. Any consultations completed must be presented to the attending over the phone. If necessary the attending will come in as well.
9. If the fellow spends several hours in the hospital after 12AM, they must contact the chief fellow and not return to the hospital unless a sufficient rest period has taken place.
10. All non-emergent consults need to be given to the consult fellow early the next morning (or consult attending at NS during the weekend).
11. Any issues regarding patients of our attendings (faculty practice) that occur while on-call must be addressed appropriately and then communicated to the concerned attending on the next working day. E-mail is the preferred method of communication. The subject must include “PHI” as the information being passed via e-mail is protected health information.
CALL- NS
1. Call at NS officially begins at 5pm and ends at 7am. Accordingly, weekend call is from 5PM Friday to 7AM Monday.
2. NS Weekend call involves rounding in the MICU and seeing MICU consults from 7AM-6PM. The pulmonary service patients will be seen by the on-call Pulmonary consult/ACCT attending, including any new pulmonary consults during the day. The fellow will continue to cover the answering service from 5PM-7AM. Pulmonary consults called during this time will be seen by the attending in the morning unless the consult is emergent and needs to be seen that night. The on-call fellow must inform the attending in the morning of any consults called overnight.
3. Pulmonary consults may be requested during nights and weekends. Consultations requested during those hours are usually called through the service. It is the responsibility of the on-call fellow to determine if the patient needs to be seen that night or if the consult can wait until morning. Detailed information needs to be requested in order to make a safe decision. When in doubt it is better to go in and see new consults. One exception to this rule is consults requested by the obstetric service, which must all be seen as soon as possible. The fellow must discuss all urgent and OB consults with the on-call attending.
4. For any issue that requires the fellow to return to the hospital, the on-call attending needs to be notified. Any consultations completed must be presented to the attending over the phone. If necessary the attending will come in as well.
5. If the fellow spends several hours in the hospital after 12AM, they must contact the chief fellow and not return to the hospital unless a sufficient rest period has taken place.
6. All non-emergent consults need to be given to the consult fellow early the next morning by 7 AM (or consult attending at NS during the weekend).
7. Any issues regarding faculty practice patients that occur while on-call must be addressed and then communicated to the attending the next day via e-mail or phone call. The email subject must include “PHI” as the information being passed via e-mail is protected health information.
8. If a patient from pulmonary clinic or the faculty practice identifies themselves as one of our patients on presentation to the ER the pulmonary fellow will be called. The fellow will obtain as much information as possible from the referring attending and go in to evaluate the patient. If there is any question of whether the patient needs to be seen after hours this must be discussed with the on call attending.
9. If a patient from the faculty practice is admitted the fellow on call must notify their faculty attending by 8am the latest the next morning, even though the on call attending was notified about the patient. The same holds true for emergency calls from patients after hours. If any of our patients call the service with a problem you must let their faculty attending know in the morning by 8am. If the problem is a serious one you should immediately call the on call attending. Similarly, if a patient calls repeatedly, notify the on call attending who will decide if the primary faculty attending needs to be called.

CONFERENCES
A detailed conference schedule will be posted on the fellows’ website, but the general conference schedule is as follows:
Monday:

*8:30 AM – 9:30 AM  Radiology Conference with Dr. Rakesh Shah (1st Floor NS Radiology Dept)

*12:00 PM – 1:00 PM  Ultrasound Conference (Fellows Rm @ NS; Conference Rm @ LIJ on 6th floor)
Tuesday:

8:30 AM – 9:30 AM  Sleep Conference with Dr. Greenberg (Sleep Disorders Center on Community Dr)

*12:00 PM – 1:00 PM  Physiology Conference (Fellows Rm @ NS; Conference Rm @ LIJ on 6th floor)
Wednesday:

7:45 AM – 8:45 AM  Lung Cancer Conference (Monter Cancer Center – Multidisciplinary)

*12:00 PM – 1:00 PM  Case Management Conference (Fellows Rm @ NS; Conference Rm @ LIJ)**
Thursday:

8:00 AM – 9:00 AM  Medicine Grand Rounds (NS – Rusk auditorium; LIJ – Main Conf Rms 2nd floor)

12:00 PM – 1:00 PM  Journal Club or Pathology Conference (notification e-mail will precede conf)
Friday:

8:00 AM – 9:00 AM  Pulmonary, Critical Care, & Sleep Medicine Grand Rounds
* Teleconferenced between NS & LIJ
** Case management conference is presented by the consult fellow at NS & LIJ. Each fellow will present one case with a maximum of 10 slides on powerpoint. The presentation should not exceed 20 minutes to allow time for Q&A.
Other conferences: PFTs – small group sessions with Dr. Talwar that will be scheduled by the chiefs
All conferences are mandatory to attend. Only exception to this is if you are the MICU fellow and there is an on-going emergency that requires your presence in the MICU. If you miss conference for any other reason, please call one of the chief fellows and let them know. The MICU fellow is exempt from radiology, sleep and lung cancer conference.
OTHER ISSUES


  1. All schedules are final and up-to-date versions are available on the fellows’ website. If you need to change anything for any reason, please discuss this with your chief fellows. The schedule is extremely tight and any change potentially affects someone else in the schedule. There are clinics, lectures, weekends, vacations, etc to cover.



  1. When requesting a change in schedule, you must first take a look at the block schedule, clinic schedule, and pulmonary rehab schedule to make sure that you are not scheduled for any of these mandatory assignments prior to making a change. A schedule change request form will need to be completed and signed by the Program Director.




  1. All fellows work as a team and are here to help each other out. If there are any issues, please always feel free to discuss the matter with the chief fellow and / or the program director as needed.


Welcome to our team!

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