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Clinical Rotations

Clinical Rotations: Inpatient

These 19.5 months of clinical activity are distributed over the three-year fellowship. The program aims for flexibility in scheduling, but typically tries to front-load clinical work. Most fellows will have 8.5months, 5 months and 3.5 months of clinical time in their first, second, and third years, respectively. See a typical training schedule. There are three major inpatient rotations associated with the DHMC fellowship. Fellows have a minimum of 1: six months on the Mary Hitchcock Memorial Hospital (MHMH) pulmonary consultation service, six months supervising housestaff in the MHMH combined medical-surgical-trauma intensive care unit (ICU), and six months at the White River Junction Veterans Administration Hospital (VAMC), where fellows participate in both intensive care and the inpatient pulmonary consultation service.  Two weeks are spent at an off-site ventilator-weaning facility.

  • Inpatient Pulmonary Consultation Service at MHMH: Pulmonary training includes six months on the inpatient consultation service at MHMH. The first month of the fellowship is spent on this service to give the fellow ample time to focus on learning the systems of care at our main teaching site. On this service, the fellow is responsible for performing all new inpatient and emergency department consultations at MHMH. He/she also receives urgent patient and outside provider calls and gives advice appropriately. Additionally, urgent outpatient evaluations and procedures are performed by the inpatient consultation fellow with attending supervision.
  • Critical Care Medicine at MHMH: Six months of critical care medicine are scheduled as one month blocks in the MHMH intensive care unit, spread over the three years of fellowship training. Fellows spend two month-long blocks on each of the trauma, surgical, and medical (thoracic) ICU services. We try to schedule the first ICU month well into the first year, to allow the fellow time to have developed some expertise in pulmonary diseases and procedural skills before assuming the increased responsibilities of supervising house staff in a multi-disciplinary medical-surgical-trauma Intensive Care Unit. A newly-formed night float system is in place for our fellows for the first time this year.
  • Inpatient Pulmonary Consultation Service / Critical Care Medicine at VAMC: Six months of training occurs on the inpatient pulmonary consultation service at the Veterans Administration Medical Center in White River Junction, VT. The VAMC also affords fellows the opportunity to supervise housestaff in a 7-bed combined medical-surgical intensive care unit, while simultaneously affording numerous opportunities for both inpatient and outpatient procedures.
  • Long-term Ventilator Facility: A two-week rotation at the Hospital for Special Care in New Britain, CT, will take place during a fellow's third year. During this rotation, fellows will be directly involved in the management of patients with chronic ventilator dependency.

Clinical Rotations: Outpatient

In addition to inpatient responsibilities, each fellow participates in two half-day outpatient continuity clinics each week throughout the three year fellowship. Fellows present all initial pulmonary outpatient evaluations to a faculty member for discussion and review. Thereafter, the fellow assumes primary responsibility for the patient. This supervised and graded responsibility is closely monitored by attending faculty. A faculty member is always available for discussions and back-up assistance.

  • DHMC Outpatient Clinic: New fellows assume care of outpatients from the previous graduating fellow, while also building their own practice with new patient evaluations, most of which are outside referrals. Schedules typically involve two new patients weekly, with two to four follow-up patients weekly.
  • VAMC Outpatient Clinic: VAMC clinic functions in a similar manner to DHMC clinic, but most patients are already established within the VAMC system. VAMC clinic involved one to three new patients weekly, with two to four follow-up patients weekly.

Procedural Skills

During the twelve months of inpatient pulmonary consultation time at MHMH and the VAMC, fellows participate in a myriad of procedures, including:

  • Conventional bronchoscopies, with the opportunity to participate in endobronchial ultrasound cases, as well as other highly-specialized interventional procedures, including airway dilatation, Nd-YAG laser vaporization, argon plasma coagulation, and stent placement.
  • Thoracenteses.
  • Pulmonary function tests involving measurement of flow rates, lung volumes, and diffusing capacity, in addition to methacholine bronchoprovocation challenge and cardiopulmonary exercise testing.

Clinical time in the ICU provides opportunities for acquiring and honing skills, including: the placement of:

  • Central venous catheters which may include pulmonary arterial catheters.
  • Arterial lines.
  • Endotracheal tubes
  • Chest tubes
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