The Department of Anesthesiology at the University of Texas Medical School at Houston
Department of Anesthesiology
The Department of Pediatrics

Fellowships

 Fellowships in the Department of Anesthesiology


Critical Care Medicine Fellowship

WELCOME

Welcome to the Critical Care Medicine Fellowship Program of the Department of Anesthesiology, University of Texas Health Science Center at Houston (UTHSC). This is a brief introduction to the program and contains an overview of the program, the faculty, facilities, fellow’s responsibilities and evaluation criteria. The resources at your disposal are considerable. There is computer access to the University of Texas M. D. Anderson Cancer Center (UTMDACC) library on-line journals, Pubmed, medical texts and pharmaceutical databases as well as the commonplace laboratory data and a variety of scan images. The multidisciplinary team is composed of doctors, ethicists, pharmacists, dieticians, physiotherapists, respiratory technicians, advanced nurse practitioners and a physician assistant. I hope that you will become a dynamic member of this critical care team.

The faculty will help you develop the clinical judgment and skills necessary to perform as an attending upon completion of this program. My door is always open to discuss any problem encountered in any sphere of practice or discuss ideas on improving patient care. I encourage you to avail yourself to the unique opportunities for research and publications while you are with us. My faculty and I will assist you to become a confident practitioner of critical care medicine who will be a reflection of this unit.

Thomas W. Feeley, M.D.
Helen Shafer Fly Distinguished Professor of Anesthesiology
Vice Present, Medical Operations and Head, Division of Anesthesiology and Critical Care at
The University of Texas M.D. Anderson Cancer Center

THE TEXAS MEDICAL CENTER

The Texas Medical Center (TMC) is the largest medical center in the world. The TMC is formed of 42 institutions that include 13 renowned hospitals, two medical schools, four nursing schools, and schools of dentistry, public health, pharmacy among others. The TMC encompasses more than 700 acres and consists of more than 100 permanent buildings, 60,000 parking spaces, 22 million gross square feet in physical plant space and 12 miles of private and public streets and roadways. There are more than 6,000 licensed hospital beds and more than 5 million total patient visits/year with thousands of patients coming from all over the world. More than 60,000 people work in the TMC, which has a $4.6 billion, combined operating budget for its member institutions. The TMC has an $11.5 billion indirect impact on Houston's economy. The center is also a worldwide leader in research. Between the years 1995 and 2000, the Texas Medical Center member institutions received more than US$ 2.2 billion as grants. The center is also very active and successful in education, and volunteer work.

CLINICAL AND EDUCATIONAL FACILITIES AT UTHSC/UTMDACC

The Anesthesiology-Critical Care Medicine Program has seven intensive care facilities disseminated in the UTHSC and UTMDACC in the Texas Medical Center. The Shock-Trauma Intensive Care Unit (STICU), the Neurosurgical Intensive Care Unit (NCCU), the Burns Unit, the Liver Transplant ICU and the Pediatric ICU at Memorial Hermann Hospital and the Surgical and Medical ICU’s at UTMDACC. Among them the trainees have a total of more than 100 beds and more than 25 ICU attendings. The ratio of attendings to fellows (>10 to 1) is greater than the minimum required by the ACGME (1 to 1) and are available 24 hours a day.

The units have a ratio of 1 to 1 and 1 to 2 nurses per patient depending on the severity of the illness. A number of technicians and respiratory therapists at all levels assist in the management of the critically ill.

State of the art equipment (Transcranial Doppler, Lithium dilution cardiac output and Esophageal Doppler for continuous cardiac output monitoring, Xe-CT scan, Thromboelastigram, etc) is available in all the units and the technical support is readily available to support any malfunction. All the laboratory facilities supporting the management of critically ill patients are available 24 hours a day including toxicology, blood gases and chemistries, as well as radiological facilities like CT, Angio and MRI. Cardiology services are available around the clock (consults, Echocardiography, electrophysiology, etc.) Infectious disease specialists provide a similar service in the management of septic patients.

There are numerous library facilities in the Medical School and at the Jesse Jones Library of the Texas Medical Center, and Medline service on-line is available through the unit computers. Conference rooms are available in each department at the UTHSC Medical School building as well as in the units

MEMORIAL HERMANN HOSPITAL

Memorial Hermann Hospital (MHH) was established in 1925 and was the first hospital to open in the Texas Medical Center. MHH is one of only two adult Level 1 trauma centers and the only pediatric trauma center in the city. MHH is part of the Memorial Healthcare System, a not-for-profit organization that provides health care through its more than 11 hospitals across the Houston area. It is also one of the hospitals of the University of Texas Health Science Center at Houston. MHH has a capacity of more than 600 beds (818 licensed beds), more than 30% of which are ICU beds. Medical care is provided for 15,000 patients per month and more than 40,000 trauma cases per year. Memorial Hermann Life Flight air ambulance services operate a fleet of three helicopters providing emergency rescue and air transport services to a multi-county area. As the primary teaching hospital for The University of Texas Medical School at Houston, MHH provides comprehensive services in surgery, internal medicine, pediatrics, obstetrics and cardiology as well as cutting-edge research in a variety of medical specialties.

There are multiple ICU opportunities at Memorial Hermann Hospital including the Shock-Trauma Intensive Care Unit (STICU), the Neuro-trauma Intensive Care Unit (NTICU), the Burn ICU, the Liver Transplant ICU, and the Pediatric ICU.

Shock Trauma Intensive Care Unit, Memorial Hermann Hospital

The Shock Trauma ICU (STICU) at Memorial Hermann Hospital is a 20 bed ICU that admits patients 14 and older. The STICU supports a level one trauma center with a life flight service that cares for over 40,000 trauma victims per year. The majority of patients admitted to the STICU have suffered some form of trauma but others include general surgery, orthopedics, ENT, OB-GYN or OMFS.

The STICU team acts as a consultant service. It consists of a board certified critical care attending (either surgery or anesthesiology), a critical care fellow (either surgery or anesthesiology), a PGY-2, 3, or 4 anesthesiology resident, a PGY-2 surgery resident, a PGY-1 anesthesiology resident and PGY-1 surgery resident. The team may also include 4th year medical students. The critical care fellow is expected to perform as a junior attending.

MDACC ICU ROTATIONS

Medical and Surgical Intensive Care Units

M.D. Anderson Cancer Center is a world-renowned cancer research and treatment hospital and referral center. M.D. Anderson received US News & World Report’s #1 ranking among cancer hospitals in 2002. Patients come to M.D. Anderson from around the world seeking the most current and aggressive treatment possible for their malignancies. Many patients are enrolled in investigational/research protocols. The cancers and many of their treatments are associated with significant end-organ side effects that require intensive care management. Adverse sequelae related to treatment, combined with the morbidity associated with the tumors alone, provide for very complex patient management opportunities and a very exciting place to work.

Both surgically and medically critically ill patients are admitted to the ICU and MD Anderson. Surgical patients admitted to the ICU are usually recovering from surgical interventions for their cancer. Given the complex nature and often-advanced state of many of the cancers our surgeons treat, these patients frequently suffer significant postoperative organ dysfunction and need aggressive interventions to manage and prevent organ failure. As a fellow you will have the opportunity to work with world-renowned surgeons from all surgical disciplines and are expected to coordinate the care of their patients with the primary team and other consultants

Medical patients admitted to the ICU have cancers that are not amenable to operative intervention. This may be due to the advanced state of their cancer or because their cancer is better managed with chemotherapy and/or radiation therapy. These patients often suffer significant morbidity due to the advanced nature of their cancer or because of the side effects of chemotherapy and radiation therapy and need aggressive interventions. You will have the opportunity to work with world-renowned medical oncologists and coordinate the care of these critically ill patients.

The intensive care units are staffed by board certified/eligible critical care anesthesiologists, pulmonologist, and surgeons who are readily available and eager to instruct you in the science and art of critical care. As the fellow you will be part of a multidisciplinary team that includes anesthesiology residents, medical students, ethicists, pharmacists, dieticians, physiotherapists, respiratory technicians, advanced nurse practitioners and a physician assistant.

In 1999 The University of Texas MD Anderson Cancer Center opened its newest building, the Alkek Hospital. The entire seventh floor of this new structure houses the 54 bed state-of-the art intensive care unit. Generous financial support from M.D. Anderson Hospital and an administration that believes in practicing on the cutting edge of critical care ensures that we have the latest technology available in our ICU.

FELLOWSHIP OBJECTIVES

During the year of critical care fellowship training under board certified/eligible intensivists, the fellows will be exposed to a wide range of opportunities allowing them to develop the clinical judgment and master a wide range of skills required for the practice of critical care. While pursuing their training in critical care, the fellows will strive to provide optimal care to the patients in the intensive care unit and are expected to:

A. Master organ system based comprehensive care of the critically ill patient including diagnosis and management of the following disorders, their sequelae, and the sequelae of their treatments:

1. Neurologic system: cerebrovascular accident, head/brain trauma, altered mental status, agitation/sedation issues, spine injury, meningitis, ventriculostomy management, elevated intracranial pressure

2. Cardiovascular system: arrhythmias, acute myocardial infarction/ischemia, congestive heart failure, cardiogenic shock, hemodynamic instability, deep venous thrombosis

3. Respiratory system: pneumonia, adult respiratory distress syndrome, complex airway management, acute respiratory distress, hemo/pneumothorax, empyema, advanced ventilator management, non-invasive positive pressure ventilation., pulmonary toilet, chest trauma, pulmonary embolism

4. Gastrointestinal system: ileus, bowel obstruction, enteral nutrition, diarrhea, constipation, abdominal trauma, pancreatitis, hepatobiliary disorders, gastrointestinal bleeding, ulceration

5. Genitourinary system: acute renal failure/insufficiency, urinary tract infection

6. Integumentary system: prevention and management of pressure ulceration, complex wound care

7. Hematologic system: anemia, coagulopathy, platelet disorders, blood borne tumors

8. Infectious disease: fever, leukocytosis, antibiotic selection, septic shock, antibiotic resistant pathogens

9. Fluid and Electrolyte: electrolyte disorders, intravascular fluid management, hypovolemic shock, colloids versus crystalloids, total parenteral nutrition

10. Rehabilitation of the critically ill patient

11. Cancer treatment side-effects

12. Be able to diagnose death and manage the end-of-life process

13. Be familiar with and able to initiate and sustain the organ donor process where appropriate

B. Develop the leadership skills necessary to lead a multidisciplinary intensive care unit team

1. Be able to effectively utilize the strengths of the various ancillary services associated with the care of the critically ill patient including nurses, pharmacists, nutritionists, physical therapists, occupational therapists, critical care nurse practitioners, advanced practice nurses, respiratory therapists, social workers, and case managers.

2. Learn the fundamentals of intensive care unit administration
a. administrative skills
b. billing and coding issues

3. Be skilled at managing interaction between physicians of multiple services who have a stake in the care of the patient

4. Be adept at communicating end-of-life process with families

5. Attend meetings related to critical care which are attended by other critical care faculty

6. Participate in orientation of residents and medical students to the STICU, MDACC ICU at the start of the rotations

C. Attend didactic learning sessions and develop teaching skills

1. Attend daily lectures with the residents on current critical care issues

2. Lead daily ICU rounds under the supervision of the ICU physician.

3. Prepare a new lecture for residents and/or students each month so that the fellow has 10 prepared lectures on critical care topics at the completion of the fellowship

4. Attend and present at a critical care journal club once per month

5. Attend a Fundamentals of Critical Care Support course

6. Maintain current Basic and Advanced Cardiac Life Support status

7. Maintain current Advanced Trauma Life Support status

8. Join local and international societies pertinent to the practice of critical care (paid for by the department of critical care)

9. Remain current with the critical care literature

10. Fellows will be required to take the Society of Critical Care Medicine’s Multidisciplinary Critical Care Knowledge Assessment Program Examination to see that their didactic knowledge is progressing appropriately and to identify areas that need further study

11. Read the provided Selected Readings in Critical Care to give you an idea of what is the current state of knowledge in the field of critical care medicine. These article deal with the education process from the medical student level to the fellowship level. Hopefully, these articles will improve your understanding of the learning and teaching process in critical care from the lower stages, and also help you to understand what are the needs of the medical students during their rotation through the intensive care units

12. Remember that the guidance and teaching of the medical students in this period are also part of your responsibilities as a fellow

13. The fellow will have AT LEAST one day free from clinical responsibilities a week for study and lecture preparation

D. Acquire the procedural skills necessary for the practice of critical care which should include:

1. Advanced airway skills including bag/mask ventilation, endotracheal intubation, fiberoptic bronchoscopy, cricothyroidotomy, retrograde intubation, laryngeal mask airway

2. Thoracentesis

3. Thoracentesis tube placement and management

4. Pericardiocentesis

5. Central venous catheter placement (internal jugular vein, subclavian vein, femoral vein)

6. Venous cut down

7. Intraosseous infusion

8. Arterial catheter placement

9. Pulmonary artery catheter placement and management

10. Esophageal doppler placement and management

11. Percutaneous gastrostomy placement

12. Percutaneous tracheostomy placement

13. Nasojejunal tube placement
E. Be introduced to research and stimulate its practice in critical care medicine

1. The opportunity is available to spend up to 3 months performing basic science research under the direction of the chief of critical care research.

2. Upon choosing to spend time in the research lab the fellow will be provided with a copy of Conducting Research in Anaesthesia and Intensive Care Medicine.

3. The fellow will be given 5 days of continuing medical education leave and be provided with predetermined funds from the critical care department for travel, lodging, meeting fees, and meals.

4. The fellow is expected to participate in at least one clinical research project and submit an abstract to the appropriate national organization.

5. If the fellow has the opportunity to present research at a medical meeting every attempt within reason by the department of critical care will be made to cover the fellows’ expenses associated with the meeting.

RESEARCH FACILITIES

The intensive care units have excellent conditions for research. Many clinical studies are in progress. The large number of patients with very interesting pathologies not only allows for experience, but the ability to complete studies in short periods of time. The time necessary for the research projects and funds from the department are available. The attendings are all research oriented, and with projects under way in the ICU and laboratories of the department of Anesthesiology. Numerous papers based on models of tissue ischemia, coagulation, sepsis, circulation, new modes of ventilation and others developed by the members of the faculty are published every year.

For those with an interest in basic sciences there are more than four basic science laboratories in the department. For more information seek the advice of the director of the fellowship program.

FACULTY

UTHSCH Anesthesiology MDACC Pulmonary Medicine
UTHSCH General Surgery MDACC Cardio-Thoracic Surgery
MDACC Critical Care MDACC Pediatrics

The academic members of the faculty are from the departments of Anesthesiology and General Surgery, and they are:

The University of Texas Houston Health Science Center
Department of Anesthesiology

Stephen J. Koch, MD
Associate Professor
Department of Anesthesiology

Young Su, MD
Assistant Professor
Department of Anesthesiology

The University of Texas Houston Health Science Center
Department of General Surgery

James H. “Red” Duke, MD
Professor
Medical Director Life Flight
Department of Surgery

Ernest Gonzalez, MD
Assistant Professor
Department of Surgery

Rosemary Kozar, MD
Assistant Professor of Surgery
Department of Surgery

Drue Ware, MD
Assistant Professor
Department of Surgery

The University of Texas M.D. Anderson Cancer Center
Department of Critical Care

Thomas Feeley, MD
Professor and Head
Anesthesiology and Critical Care

Kristen Price, MD
Associate Professor and Chair
Department of Critical Care

Gregory Botz, MD
Assistant Professor
Department of Critical Care

Karen Chen, MD
Assistant Professor
Department of Critical Care

Bernhard Riedel, MD
Associate Professor
Department of Anesthesiology

Donna Calabrese, MD
Assistant Professor
Department of Critical Care

Diego De Villalobos, MD
Assistant Professor
Department of Critical Care

Trisha Dipprey, MD
Clinical Instructor
Department of Critical Care

Susan Gaeta, MD
Assistant Professor
Department of Critical Care

Imrana Malik, MD
Assistant Professor
Department of Critical Care

Dana Martin, MD
Assistant Professor
Department of Critical Care

Joseph Nates, MD
Assistant Professor
Department of Critical Care

Egbert Pravinkumar, MBBS
Assistant Professor
Department of Critical Care

The University of Texas M.D. Anderson Cancer Center
Department of Critical Care – Pulmonary Medicine

Burton Dickey, MD
Professor and Chairman – Pulmonary Medicine

Georgie Eapen, MD
Assistant Professor
Department of Critical Care – Pulmonary Medicine

Carlos Jimenez, MD
Assistant Professor
Department of Critical Care – Pulmonary Medicine

Vickie Shannon, MD
Associate Professor
Department of Critical Care – Pulmonary Medicine

Roberto Adachi, MD
Assistant Professor
Department of Critical Care – Pulmonary Medicine

Diwakar Balanchandran, MD
Assistant Professor
Department of Critical Care – Pulmonary Medicine

Scott Evans, MD
Assistant Professor
Department of Critical Care – Pulmonary Medicine

The University of Texas M.D. Anderson Cancer Center
Department of Cardio-Thoracic Surgery

Garrett Walsh, MD
Professor
Department of Cardio-Thoracic Surgery

The University of Texas M.D. Anderson Cancer Center
Department of Pediatrics

Alan Fields, MD
Professor
Department of Pediatrics

Carol King, MD
Assistant Professor
Department of Pediatrics

Rodriga Mejia, MD
Assistant Professor
Department of Pediatrics

Jose Cortes, MD
Instructor
Department of Pediatrics

The following two pages are located on the secure server and can only be accessed by those listed in the UTHSCH anesthesiology mail group.

Fellows Responsibilities at MDACC

MDACC Check-In Procedures for Fellow/Resident/Medical Student