As a first year fellow you spend most of your time on service and on call. This is the best 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. During those 26 weeks you spend a similar amount of time on each of the 3 ICU floors.
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 cardiothoracic surgeons daily.
The 4th floor is our trauma/surgical ICU; here you learn post-operative management of a variety of patient types including post-operative neurosurgery patients, general surgery patients and solid-organ transplant patients. You are also responsible for responding to trauma activations in the ER 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. Traumas often provide a fast-paced multidisciplinary team experience to say the least. The 4th floor PICU provides you with some quick turnaround of surgical patients, intensive exposure to 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, 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. While on call, you will be responsible for covering one of the three PICU floors. Nights on call provide increasing amounts of autonomy throughout your first year. It is reassuring to know that there is always one of your attendings “in-house” and readily available for patient care and educational opportunities. 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.
Two months are spent on an anesthesia rotation where you are able to learn and refine your airway management, central line placement and peripheral IV placement skills. 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, you spend less time on clinical service in the PICU. You spend 14 weeks on service during the first year compared to 26 in the first year of fellowship. This year 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.
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 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.
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 and finishing your 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 residency.
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 starting a bowel regimen in patients who are receiving continuous narcotic infusion. 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. 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.
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.