- First Year Fellow
In our first year of fellowship we spend 26 weeks on service in the PICU, divided into six 4-week blocks and one 2-week block. A typical day on service involves arriving at the hospital just before 7 a.m. to print a patient list and check on labs. Sign out is at 7 a.m. every day where we hear about overnight events and new admissions from the on-call person. Then we see patients until 8 a.m. when we have radiology rounds and review x-rays as a team. On the 3rd floor (Cardiac ICU) we review films and overnight events with the cardiovascular surgeons and on the 4th and 5th floors (Surgical and Medical ICU) we review films with a radiologist. We generally start walking rounds at 8:30 a.m. and finish between 11 a.m. and noon. Every Monday and Wednesday at noon we have Research Conference and Core Curriculum Conference for the whole Critical Care section. Tuesday noon conferences alternate between Professors Rounds which is a didactic session for fellows, nurse practitioners and rotating residents and fellows that focuses on one particular topic or disease and we invite a basic scientist or clinician with expertise in that area, and cardiac-focused didactics. The afternoons are spent following up on patients’ clinical condition, admitting new patients, and documenting the daily progress notes in EPIC, our hospital's electronic health record. Evening sign-out starts around 4 p.m. and is usually complete by 5 p.m.
In our first year we have 7 calls per month. Night calls are a good time to walk around the unit and think about the patients’ pathophysiology and troubleshoot as needed. We become more comfortable as the year progresses and realize that help is only a few feet away.
For our non-service months we have the opportunity to broaden our clinical and practical knowledge base. We spend two 4-week blocks with anesthesia focusing on airway management and principles of anesthesia. Four 4-week blocks are dedicated for research where can we choose a faculty member to work with and begin thinking about our own project to work on. The multiple research blocks and the large number of faculty available to work with ensures that we will identify an area of interest and a faculty mentor early on. To aid us in our research project we have a Scholarship Oversight Committee comprised of a faculty member from outside the division, and several Critical Care faculty members. In our first year we also spend 2 weeks with the transport team to gain experience and comfort with the transport process. Finally, we have 22 vacation days during our first year that we can take during our non-PICU months.
We also have administrative responsibilities during our first year and become involved in committees in areas of our particular interest. We spend time teaching residents and give a lecture series on PICU topics that is case-driven and geared towards board topics. Each year the first year fellow class completes an online quality improvement curriculum and begins to collaborate to choose a quality improvement project which will be implemented over the next two years of fellowship. I enjoy sharing an office with my co-fellows since it gives us the opportunity to get to know each other and exchange ideas.
As one can see our first year is a busy time that allows us to have a great deal of clinical exposure. During the course of a year we grow in our roles as fellows and take on more responsibility and improve our leadership skills. Children’s Hospital of Wisconsin is a great place to learn and train.
- Second Year Fellow
As a second year Pediatric Critical Care Fellow, your clinical time decreases significantly. You go from being on service for 26 weeks in your first year, to being on service for 14 weeks your second year. You have a lot of protected time to pursue your research or other educational activities, including a Master’s degree from the Medical College of Wisconsin. If desired, fellows are typically able to obtain a Master’s Degree during their 2nd and 3rd years of fellowship and get it completed before fellowship is completed. Tuition is paid by the Department of Pediatrics as a taxable benefit. All of our Pediatric Critical Care faculty and fellow fellows are supportive of those obtaining a Master's degree. During weeks on service they are allowed to leave the PICU for class without any problems.
If on service, a typical day begins by meeting in the PICU at 7 a.m. for sign-out from the on-call fellow. We go to Radiology for rounds at 8 a.m. followed by work rounds in the PICU. At noon we go to lunch (both fellows and attendings) or to noon conference on Mondays, Tuesdays, and Wednesdays. After lunch/conference, it is back to the PICU for more work, new admissions, and procedures. Depending on how busy it is there is usually some type of teaching which takes place with one of the senior fellows or one of the attendings for the entire group, including residents. At 4 p.m., we sign-out the unit to the on-call team and adjourn for the day.
During your second year you will also spend 4 weeks doing a Pulmonary rotation. During this rotation you will have the opportunity to do bronchoscopies, learn more about PFTs, sleep studies, respiratory equipment and home ventilators, and spend some time seeing new consults.
There is great camaraderie in this PICU. We are always having fun. It is fun to be on service and to be around in this PICU.
- Third Year Fellow
Each day can be quite different for a third year PICU fellow here at Children’s Hospital of Wisconsin! Since the service time is only 14 weeks, there are 38 weeks out of the year to do a myriad of other activities. Most of that time is spent working on a scholarly activity. For some, it means going to a research lab and working on experiments. For others, it means coming to the office and working with statisticians reviewing data that has been collected for a clinical research study. For me, it means going to class. I am working on a master’s degree in bioethics as well as a qualitative research study. Thus I spend my time in the classroom, on the wards doing ethics consultation, in the office reviewing data I’ve collected for my project or in the library reading materials for class.
In addition to the time spent working on the scholarly activities, each of us participate in administrative duties. Some fellows make the call schedules, others make the transport schedules. This involves a fair amount of coordination among the fellows, nurse practitioners and acute care specialists.
Beyond the individual duties, all fellows participate in a quality improvement project. These projects typically start in the second year and continue through the rest of fellowship. One recent project focused on making sure that all trauma patients had accurate weights on admission to the unit. We also completed a project looking at ways to diminish the costs, both fiscally and physically, surrounding lab orders in the PICU. We used a daily reminder sheet at each bedside to remind us to assess the frequency of lab draws such that we can minimize the blood loss to each patient and the financial costs associated with it. This project went so well that these reminder sheets are at each patient’s bedside today and help remind us not only of lab draw frequency, but also to review nutritional goals, discharge plans, pain and sedation goals and whether or not invasive tubes and lines are necessary for that patient.
Personal goals can also be achieved during the third year of fellowship. For example, some fellows spend additional time learning procedural sedation during elective time at St. Mary’s hospital in Madison. Some fellows spend time doing international health, going abroad and working to help third world communities. Some fellows spend more time in the operating room, finessing procedural skills or performing bronchoscopies. Some fellows work on education curriculum, mock codes, teaching PALS (pediatric advanced life support) or ATLS (advanced trauma life support). We are very fortunate to have such flexibility to tailor the third year in the way we see fit.
Finally, the third year is a very special time for fellows while on service. The fellow now leads daily rounds, taking the lead with families and patients, as well as with consultants of other services. Leadership and autonomy are built during these times, when the fellow is acting as the attending (or as we affectionately call it, “pretending”). In addition, we have the opportunity to carry the “3939” pager, which is the admitting and transport pager. We learn to manage patients over the phone and to coordinate patient placement in the PICU.
Thus, as one can easily see, the third year of fellowship can be quite unique, depending on the interests of each individual fellow. The third year of fellowship is the time where you transition to becoming an attending. Yet there is still an array of other activities that make the third year one of the most exciting times of fellowship! There is tremendous growth and steady transition from being a fellow to becoming an attending.