As a first year fellow you spend a lot of time on service and on call. This is a surefire way to get you more comfortable in the PICU and allow you to gain a large chunk of clinical experience at the beginning of your three years of fellowship. At CHW we spend 26 weeks on service in our first year followed by 14 weeks our second and third year. During those 26 weeks you spend an equal amount of time on one of each of the 3 PICU floors. The 4th floor is our trauma/surgical ICU; here you learn post-operative management of a variety of patients including post-operative neurosurgery patients, general surgery patients and transplants (liver and kidney). You are also responsible for responding to trauma activations when on service on the 4th floor as these patients frequently are admitted to the PICU. As a critical care fellow you play an integral role in the traumas that come into the hospital. You are in the trauma bay and expected to perform the primary survey, perform procedures that may be needed and assist in resuscitation if the trauma progresses to a code arrest. Traumas can be quite exciting to say the least. The 4th floor PICU provides you with some quick turnaround of surgical patients, very sick TBI and transplant patients and an opportunity to get to know the staff and fellows of the various surgical specialties as together you are a team co-managing the patients. The 5th floor PICU is more of a medical PICU where you will see a wide variety of patients but specifically gain expertise in management of sepsis and critically ill BMT and oncology patients. Here you will also work with various subspecialists who will frequently be present on rounds providing a true multidisciplinary approach to patient care. As the fellow on the 5th floor you are responsible for responding to hospital-wide code blue pages as well as rapid response pages. These are opportunities for you to help in stabilization of acutely ill patients on the general floor and assist in their transfer to the PICU if necessary. The 3rd floor is our CICU and where you will spend 2.5 months your first year. We have a large and thriving cardiac program at CHW and as a result we do a large volume of cardiac surgery. Here you gain a lot of experience taking care of a variety of both pre- and post-operative patients with congenital heart disease as well as patients requiring ECMO support and patients on ventricular assist devices. As with the other floors this is a true-multidisciplinary team as we round and discuss patients with the cardiologists and the cardiac surgeons daily.
While on call you will be responsible for covering one of the three PICU floors. Nights on call are a chance for a lot of autonomy in admitting patients and decision making but also being aware that the attending is in-house and readily available if you need them. As a first year fellow you are given priority for procedures as this is a time for you to begin learning and mastering routine procedural skills necessary in the PICU. 2 months are spent on anesthesia where you are able to practice airway management, central line placement and peripheral IV placement. You will gain a lot of experience with intubations, central lines, arterial lines and chest tubes and by the end of your first year will be able to supervise other providers (nurse practitioners and residents) with these procedures.
Overall your first year of PICU fellowship is an insanely busy time filled with a lot of clinical service and nights on call. At the end of the first year you will be amazed at how much your knowledge, comfort and confidence in caring for critically ill children multiplies exponentially over those 12 months.
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. This is essentially the most productive time of your fellowship. You can work on getting your research project moving and pursue other educational activities such as a Master’s degree from the Medical College of Wisconsin (Tuition is paid by the Department of Pediatrics as a taxable benefit).
If on service, a typical day begins by meeting in the PICU at 7 a.m. for sign-out from the on-call fellow. During rounds you have more autonomy (compared to a first year) and are expected to run rounds with the attending present. At noon we go to noon conference on Mondays, Tuesdays, and Wednesdays. After lunch/conference, it is back to the PICU for more work, new admissions, procedures or teaching. 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. This time also helps you learn some intricacies of taking care of the complex trach-vent patients as an outpatient.
All in all second year is a good mix of service weeks and time that you can devote to some “CV building” - Treasuring it before it finishes!
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 finishing the scholarly project. Some of the fellows have completed multiple research projects during their fellowship. There is ample support for pursuing clinical or basic science research within and outside the division of critical care. 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. Some other projects involved improving the costs surrounding lab orders, converting intravenous to oral medications as appropriate etc.
Personal goals can also be achieved during the third year of fellowship. For example, fellows spend dedicated time learning procedural sedation as an elective at St. Mary’s Hospital in Madison. Other opportunities for electives include International Health, spending time in OR to improve procedural skills including bronchoscopy. 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 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.