VIRGINIA COMMONWEALTH UNIVERSITY HEALTH SYSTEM

MEDICAL COLLEGE OF VIRGINIA CAMPUS

McGuire Veterans Affairs Hospital

PULMONARY/CRITICAL CARE CURRICULUM

Educational Purpose and Learning Objectives

2002-2003

Educational purpose:

To prepare the Pulmonary/Critical Care post-graduate resident in the practice of pulmonary medicine, with an emphasis on the following objectives:

1. The resident will develop an understanding of the scientific and clinical principles of pulmonary medicine.
2. The resident will develop the clinical and procedural skills required for the practice of pulmonary medicine, with opportunities to observe and manage inpatients and outpatients with a variety of pulmonary disorders.
3. The resident will be provided opportunities in basic science or clinical research for the development of a career in academic medicine.
4. The resident will be provided with an environment for independent learning and the development of teaching skills.
5. The principles of medical ethics will be observed.

Teaching methods:

1. Clinical rotations with academic faculty-- one-on-one preceptorship with clinical faculty during elective rotations, critical care rotations, and the pulmonary consult services at the MCV hospital and the McGuire VA Medical Center
2. Continuity clinic, Medical Specialties/Pulmonary medicine
3. Clinical rotations in the Medical Intensive Critical Care Unit and Combined Critical Care Unit (VA).
4. Electives, both off-site (community-based) and at the University /VA hospital.
5. Didactic lectures, including core curriculum lectures, research conference, fellows conference, radiology conference, medical grand rounds, journal club.
6. Computer based software
7. Direct observation and supervision for the development of procedural skills.
8. ACLS/ATLS certification
9. High-risk airway workshop
10. Study modules

Educational content: PULMONARY MEDICINE

Clinical experience in the management of a broad spectrum of pulmonary diseases, including:

1. Obstructive lung diseases, overview
2. Understand the pathophysiology and natural history, treatment and management of obstructive lung disease.
3. Asthma, diagnosis and management
4. Chronic bronchitis, natural history and management
5. Emphysema, natural history, diagnosis and management
6. Bronchiectasis
7. Bronchoscopy, diagnostic, indications
8. Bronchoscopy, interventional, indications
9. Cystic fibrosis, diagnosis, management, genetics, family counseling
10. Chronic cough
11. Dyspnea
12. Cardiopulmonary exercise testing
13. Lung Transplantation
14. Understand the indications for lung transplantation, the pharmacology of transplantation, and post-transplant management.
15. Preoperative assessment of the surgical patient with lung disease.
16. Pulmonary malignancy, primary
17. Understand the diagnosis, staging, and management of lung cancer, including multi-modality therapy.
18. Be familiar with the diagnostic and screening modalities for lung cancer.
19. Basic understanding of histopathology will be required.
20. Pulmonary malignancy, metastatic
21. Pulmonary infections, bacterial
22. Pulmonary infections, fungal
23. Pulmonary infections, Mycobacterium tuberculosis
24. Pulmonary infections, mycobacterium other than tuberculosis
25. Pulmonary infections, viral
26. Pulmonary infections, atypical
27. Pulmonary infections in the immunocompromised host
28. Diffuse interstitial lung disease
29. Pulmonary vasculitis/pulmonary hemorrhage syndrome
30. Pulmonary hypertension, primary
31. Pulmonary hypertension, secondary
32. Pulmonary cytology and histology
33. Occupational and environmental lung disease
34. Drug-induced lung disease
35. Acute lung injury due to radiation, inhalation, or trauma
36. Pulmonary manifestations of systemic disease, including the collagen vascular diseases
37. Sarcoidosis
38. Respiratory failure, acute
39. Respiratory failure, chronic
40. Respiratory failure due to adult respiratory distress syndrome
41. Respiratory failure due to neuromuscular disorders
42. Thromboembolic disease, including pulmonary embolus.
43. Understand the clinical presentation, diagnosis, and acute management of pulmonary embolus.
44. Understand the principles of thrombosis prevention and DVT prophylaxis.
45. Disorders of pleura
46. Disorders of mediastinum
47. Genetic and developmental disorders of the respiratory system
    
48. Sleep disorders

Educational content: CRITICAL CARE MEDICINE

Clinical experiences in the management of a broad spectrum of critical care illnesses, including:

1. Ethics

• Understand the principles of advanced directives, terminal care, and conflict resolution in the context of the ICU

1. Severity of Illness

• Understand the rationale, applications, and limitations of severity of illness evaluation
• Know the basic components of the common severity of illness scoring systems including APACHE II and III, MPM,
• Understand multiple organ failure or dysfunction (MODS) and the relationship of MODS to outcome

1. Hemodynamic monitoring

• Know the indications, contraindications, techniques, and potential complications for central venous catheterization
• Know the indications, contraindications, techniques, and potential complications for arterial catheterization
• Know the indications, contraindications, techniques, and potential complications for pulmonary arterial catheterization
• Interpret hemodynamic data including waveform analysis, and interpretation of sets of hemodynamic data

1. Pharmacology in the ICU

• Understand the basic principles of pharmacokinetics and how organ dysfunction and critical illness can influence it
• Appreciate the relative costs of commonly used medications

1. Advanced cardiac life support

• Know basic life support

• Know the management algorithms for shock, myocardial infarction, and cardiac arrhythmias as outlined in current ACLS

1. Endotracheal intubation, artificial airways, airway management

• Know the indications, contraindications, techniques, and potential complications for oro-tracheal and nasotracheal intubation
• Be familiar with the indications, contraindications, care, and potential complications of tracheostomy
• Know the principles of airway management and emergency alternatives to endotracheal intubation

1. Mechanical Ventilation

• Understand the principles of positive pressure ventilation
• Know the common ventilator modes, settings, alarms, and monitors
• Know the principles of mechanical ventilation for ARDS and their rationale
• Know the mechanisms, risk factors, recognition, and management of pneumothorax and barotrauma
• Understand the principles of weaning from mechanical ventilation
• Appreciate the indications, contraindications, techniques, and potential complications for noninvasive mechanical ventilation

1. Arterial blood gas and pulse oximetry interpretation and Acid / base disturbances

• Understand how blood gases are measured
• Understand how oximetry is performed and the limitations of pulse oximetry
• Know the principles of acid-base physiology and acid base disturbances
• Interpret arterial blood gases and other laboratory measurements for various acid base disturbances

1. Respiratory failure

• Understand the causes, pathophysiology, and management of various forms of respiratory failure, including hypercapnic and hypoxemic respiratory failure

1. Acute respiratory distress syndrome

• Understand the defining characteristics, causes, and pathophysiology of ARDS
• Know the management principles for ARDS

1. Pneumonia in the ICU

• Understand the pathophysiology, manifestations, prevention, diagnostic tests, and management of ventilator-associated pneumonia
• Know the agents and antibiotics for severe community acquired pneumonia

1. Life-threatening asthma

• Know the pharmacologic management options for life-threatening asthma
• Understand the principles of mechanical ventilation for life-threatening asthma

1. Shock

• Understand the various mechanisms of shock including hypovolemic, maldistributive, cardiogenic, and obstructive
• Know the principles of resuscitation from shock and monitoring of resuscitation
• Compare the characteristics and indications for common vasopressors and inotropic agents

1. Myocardial infarction

• Know the diagnostic studies and basic management of cardiac ischemia and acute coronary syndrome

1. Cardiac arrhythmias

• Identify atrial and ventricular tachyarrhythmias, heart blocks, and ECG abnormalities associated with electrolyte disturbances.
• Know the anti-arrhythmic agents, including indications, contraindications, potential adverse effects

1. Hypertensive crisis

• Know the criteria for hypertensive urgency and emergency
• Know the medications to treat hypertensive crisis, including indications, contraindications, potential adverse effects

1. Acute renal failure

• Know the differential diagnosis for acute renal failure
• Know the management principles for acute renal failure, including indications for hemodialysis

1. Fluid and electrolyte disorders

• Understand the pathophysiology, manifestations, and management of the following electrolyte disorders
• Hypokalemia/Hyperkalemia
• Hyponatremia/Hypernatremia
• Hyperosmolality
• Hypocalcemia/Hypercalcemia
• Hypomagnesemia/Hypermagnesemia
• Hypophosphatemia
• Understand the advantages and disadvantages of various forms of fluid administration (crystalloids / colloids)

1. Diabetic ketoacidosis

• Understand the diagnosis and management of DKA
• Appreciate the role of myocardial infarction, infection, and electrolyte disorders in outcome from DKA

1. Endocrine disorders in the ICU

• Know the manifestations, diagnostic tests, and management of adrenal insufficiency
• Know the manifestations, diagnostic tests, and management of thyroid storm
• Know the manifestations, diagnostic tests, and management of hypothyroidism

1. Nutrition

• Know the principles of enteral nutrition
• Know the principles of parenteral nutrition

1. Gastrointestinal disorders

• Know the differential diagnosis, evaluation and management of upper GI bleeding
• Know the differential diagnosis, evaluation and management of lower GI bleeding
• Know the evaluation and management of acute pancreatitis
• Know the evaluation and management of fulminant hepatic failure
• Know the complications, and their management, of cirrhosis

1. Hematology / Oncology disorders

• Know the causes and management of bleeding disorders, including blood products
• Know the principles of management of the neutropenic and immunocompromised patient
• Know the complications, and their management, of bone marrow transplantation

1. Nervous system disorders

• Know the causes, evaluation, and management of coma and cerebrovascular accidents
• Know the causes and management of status epilepticus
• Know the criteria and testing for brain death
• Know the causes and management of delirium and psychiatric disorders
• Know the principles of sedative and paralytic drug administration
• Know the causes, evaluation, and management of weakness and neuromuscular disorders

1. Infectious diseases issues in the ICU

• Know the principles of infection control and prevention of nosocomial infection
• Appreciate the spectrum of activity and potential adverse effects of antimicrobial agents
• Know the causes and evaluation of fever in the ICU patient
• Know the criteria, causes, evaluation, and management of septic shock

1. Miscellaneous Critical Care Topics

• Understand the principles for evaluation of poisoning and drug overdose
• Know the primary manifestations, evaluation, and management of common drug overdoses, including tylenol, salicylate, tricyclic antidepressant, benzodiazepine
• Understand disorders of temperature control such as hypothermia and hyperthermia, including evaluation and management
• Appreciate issues surrounding ICU management, billing and documentation, admission / discharge

Clinical competencies in the following technical skills:

1. Mechanical ventilation, including volume -cycled, pressure-cycled, time-cycled, and flow-cycled ventilation.
2. Non-invasive mechanical ventilation.
3. Respiratory care, including the oxygen delivery systems, continuous positive airway pressure, nebulizer therapy.
4. Management of pneumothorax, with needle insertion or chest tube drainage techniques
5. Diagnostic and therapeutic procedures, including thoracentesis, pleural biopsy, flexible fiberoptic bronchoscopy.
6. Pulmonary function testing, to assess respiratory mechanics
7. Includes spirometry, flow volume studies, lung volumes, diffusion capacity, arterial blood gas analysis
8. Management of circulation:
9. Arterial puncture and line placement.
10. Insertion of central venous or pulmonary artery balloon floatation catheters.
11. Basic and advanced cardiopulmonary resuscitation.
12. Cardioversion
13. Calibration and operation of hemodynamic monitoring systems.
14. Examination and interpretation of sputum, bronchopulmonary secretions, pleural fluid or lung tissue for infectious agents, cytology or histopathology.

Dr. Lisa Brath
Program Director

Attention: Teresa Jones
Division of Pulmonary and Critical Care Medicine
Virginia Commonwealth University
Box 980050
Richmond, VA 23298