Mayer Sagy, MD
Program Director
(718) 470-3313
Sagy@lij.edu
 

Program goals and objectives

The purpose of the training program in Pediatric Critical Care Medicine is to provide the foundation for understanding the pathophysiology of acute, life-threatening conditions as well as the physiology of advanced life support.

The program emphasizes the fundamentals of clinical diagnosis, patient assessment, and clinical management. The subspecialty residents in pediatric critical care medicine participate in the care of pediatric patients of all ages, from the infant to the young adult, and they have the opportunity to acquire the knowledge and skills to diagnose and manage patients with acute life-threatening problems. This includes the opportunity to develop competence in such areas as cardiopulmonary resuscitation; stabilization for transport; trauma; triage; ventilatory, circulatory and neurologic supports; management of renal and hepatic failure; management of poisoning and complicated hematological, infectious, and immunological problems; continuous monitoring and nutritional support. The residents may choose to have some of their clinical experience in other critical care settings such as in anesthesia, in a medical intensive care unit, in a neonatal ICU and/or in a surgical ICU. The program places major emphasis on developing a compassionate understanding of critical illness and death. The resident learns to be responsive to the emotional needs of the patients, their families, and the critical care staff.
The program teaches the pharmacological principles of medical management and provides opportunity for the subspecialty residents to apply them to the critically ill patients. Instruction in biomedical instrumentation is offered to familiarize the resident with current technology. The resident in pediatric critical care medicine also functions as a teacher and assumes some administrative responsibilities during the third year of his/her training.

Profile of Schneider Children's Hospital. (Log on: http://www.schneiderchildrenshospital.org)

Schneider Children's Hospital of North Shore Long Island Jewish Health System is a 150-bed children's hospital that opened in November 1983. The Department of Pediatrics includes additional inpatient and outpatient services at North Shore University Hospital in Manhasset NY (2 miles north of SCH). The Department of Pediatrics offers comprehensive medical and surgical services to patients from newborn to 21 years of age. A full time staff of subspecialists, including physicians, dentists, nurse practitioners, psychologists, social workers, rehabilitation therapists, pharmacists and other health professionals and technicians are well represented.

Schneider Children's Hospital is a fully accredited pediatric residency program. The hospital is also a campus of the Albert Einstein College of Medicine where the faculty holds academic
appointments.

Profile of the Pediatric Intensive Care Unit

The Pediatric Intensive Care Unit at Schneider Children's Hospital is currently a 20 bed fully monitored unit which cares for children from newborn to young adulthood. This PICU averages 1000 admissions per year and specializes in quaternary level of pediatric critical care that includes cardiothoracic surgery, extracorporeal membrane oxygenation (ECMO) and an active cardiopulmonary rescue program for patients with Acute Respiratory Distress Syndrome and patients with severe cardiac dysfunction. Patients with various life-threatening conditions such as trauma, infections and postoperative instability are also admitted to the PICU. An additional 15-bedded pediatric intensive care unit is located at North Shore University Hospital in Manhasset NY (2 miles north of SCH) where 800 patients are admitted per year and general tertiary level of pediatric critical care is practiced.

The Pediatric Intensive Care Units are currently staffed by eight full-time pediatric critical care specialists. Also, actively involved are 2 full-time pediatric cardiothoracic surgeons, seven cardiologists, 3 pediatric neurosurgeons and seven pediatric surgeons. All other subspecialties such as pediatric neurology, endocrinology, gastroenterology, infectious disease, anesthesiology, and hematology/oncology contribute their share as consultants, teachers and researchers.

The PICU at SCH has in house coverage, 24 hours a day, weekends and holidays, with a critical care fellow and second and third year
pediatric residents. Other residents and fellows from emergency medicine and anesthesia often do an elective rotation through the PICU.
Seventy registered nurses with special training and interest in critical care work in the PICU of SCH and 50 nurses in the PICU at SCH-NS location. Respiratory therapy is present 24 hours a day to assist in mechanical ventilation and other aspects of respiratory care. A supporting staff, with a bioethicist, social worker, and statistician, is available for consultations.

The Staff

Mayer Sagy, MD
Chief, Division of Pediatric Critical Care
Director, Pediatric Critical Care Fellowship Program
Division: Critical Care
Primary Address: Schneider Children's Hospital, 269-01 76th Avenue
New Hyde Park, NY 11040
Phone: (718) 470-3330 Fax: (718) 470-0159
Beeper: (718) 470-7700, #07420
Email: msagy@lij.edu
Affiliations: Long Island Jewish Medical Center
Clinical and Research Interests: The Pediatric Airway

Peter Silver, MD
Clinical Director of Pediatric Intensive Care Unit at Schneider Children's Hospital
Division: Critical Care
Primary Address: Schneider Children's Hospital, 269-01 76 Avenue
New Hyde Park, NY 11040
Phone: (718) 470-3312 Fax: (718) 470-0159
Beeper: (718) 470-7700, #07608
E-mail: psilver@lij.edu
Affiliations: Long Island Jewish Medical Center
Clinical Interests and Research: ECMO and cardiac intensive care

Kevin R. Bock, MD, D,ABSM
Section Head: Pediatric Sleep Diagnostic Center
Division: Critical Care
Primary Address: Schneider Children's Hospital, 269-01 76 Avenue
New Hyde Park, NY 11040
Phone: (718) 470-3332 Fax: (718) 470-0159
Beeper: (718) 470-7700, #03672
E-mail: kbock@lij.edu
Affiliations: Long Island Jewish Medical Center
Clinical and Research Interests: Renal Replacement Therapy and Sleep Disordered Breathing of Childhood

Sharon Dial, MD
Section Head, Pediatric Intensive Care at North Shore University Hospital
Division: Critical Care Medicine
Primary Address: North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030
Phone: (516) 562-2542 Fax: (516) 516) 562-4090
Beeper: (516) 975-2514
Email: sdial@NSHS.edu
Affiliations: North Shore University Hospital
Clinical and Research Interests: General pediatric critical care and postoperative cardiac physiology.

Gregory Kraus, MD
Division: Critical Care Medicine
Primary Address: North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030
Phone: (516) 562-2542 Fax: (516) 562-4090
Beeper: (516) 975-2851
Email: GKraus@NSHS.edu
Clinical and Research Interests: Apnea and Pediatric Airway

Brenda V. Marcano, MD
Section Head: Pediatric Transport
Division: Critical Care
Primary Address: Schneider Children's Hospital, 269-01 76 Avenue
New Hyde Park, NY 11040
Phone: (718) 470-3357 Fax: (718) 470-0159
Beeper: (718) 470-7700, #03239
E-mail: Marcano@lij.edu
Affiliations: Long Island Jewish Medical Center
Clinical and Research Interests: Pediatric Transport

Maria C. Esperanza, MD
Division: Critical Care
Primary Address: Schneider Children's Hospital, 269-01 76 Avenue
New Hyde Park, NY 11040
Phone: (718) 470-4332 Fax: (718) 470-0159
Beeper: (718) 470-7700, #03103
E-mail: Marcano@lij.edu
Affiliations: Long Island Jewish Medical Center
Clinical and Research Interests: Pediatric Sedation

Randi Trope, DO
Division: Critical Care Medicine
Primary Address: North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030
Phone: (516) 562-2542 Fax: (516)562-4090
Beeper: (917) 871-8744
Email: Rtrope@lij.edu
Clinical and Research Interests: Resident Education

Marcia Zinger, RN, MSN-CPNP, ECMO COORDINATOR
Division: Critical Care
Primary Address: Schneider Children's Hospital, 269-01 76 Avenue
New Hyde Park, NY 11040
Phone: (718) 470-3421 Fax: (718) 470-0159
Beeper: (718) 470-7700, #05053
E-mail: Zinger@lij.edu
Clinical and Interests: ECMO

Lucia Sherlock, RN, CNS
Division: Critical Care Medicine
Primary address: Schneider Children's Hospital, 269-01 76 Ave
New Hyde Park, NY 11040
Phone: (718) 470-3422 Fax: (718) 470-0159
Beeper: #05201
Email: LSherloc@NSHS.edu
Clinical Interests: ECMO, Congenital heart defects

Jennifer Marie Darcy, RN, MSN, PNP
Transport Coordinator
Division: Critical Care
Primary Address: North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030
Phone: (718) 470-3330 Fax: (718) 470-0159
Beeper: (718)470-7700 #05042
E-mail: jobrien@nshs.edu
Affiliations: North Shore University Hospital
Clinical Interests: Pediatric Transport, Advanced Life Support, Basic Life Support

Ann McGrath, RN, MSN
Assoc Administrator for Nursing
Division: Nursing Administration
Primary Address: Schneider Children's Hospital, 269-01 76 Avenue
New Hyde Park, NY 11040
Phone: 718 470-3583
Beeper: (718) 470-7700, #05312
E-mail: amcgrath@lij.edu
Clinical Interests: Pediatric transport, ECMO, BLS

Mary Beth Higgins, RN, BS
Division: Critical Care
Clinical Practice Coordinator
Primary Address: Schneider Children's Hospital, 269-01 76 Avenue
New Hyde Park, NY 11040
Phone: (718) 470-7700 Fax: (718) 470-0159
Beeper: (718) 470-7700, #05118
E-mail: mhiggins@lij.edu
Clinical Interests: ECMO, PALS, BLS

Application Requirements

Applicants for the Pediatric Critical Care training program at SCH must have completed three years of training in an accredited general pediatric residency program. Eligible applicants are invited to come to SCH for a one-day interview during which they have the opportunity to discuss their career goals and to tour the facility. The program participates in the national matching program and all final decisions are submitted to the applicant through that channel.

Duration of Training

The pediatric critical care medicine training is a three year

program. The following is a general schedule of each year:

First Year Schedule

5 months in pediatric intensive care unit

1 month elective

3 months in cardiothoracic surgery

1 month in anesthesia

1 month in research*

1 month of vacation

A course in research methods for post doctoral fellows is offered during this year by the hospital.

Second Year Schedule

3 months in pediatric intensive care unit

3 months in cardiothoracic surgery

3 month elective

2 months of research*

1 month of vacation

Third Year Schedule

1 month in pediatric intensive care unit

1 month in pediatric cardiothoracic surgery

9 months of research

1 month of vacation

*Elective months can be converted to research months.

Scope of Clinical Training

The critical care residents are involved in making the clinical diagnosis, inpatient assessment and clinical management of all the patients in the PICU. The subspecialty residents in pediatric critical care medicine participate in the care of pediatric patients of all ages, from the infant to the young adult, and they get the opportunity to acquire the knowledge and skills to diagnose and manage patients with acute life-threatening problems. This includes the opportunity to develop special competence in such areas as cardiopulmonary resuscitation, stabilization for transport, trauma, triage ventilatory, circulatory, and neurologic support, management of renal and hepatic failure, poisoning, and complicated hematological, infectious and immune problems, continuous monitoring, and nutritional support. The residents may have some of their clinical experience in other critical care settings, such as the operating room and post-anesthesia care unit, the medical intensive care unit, the neonatal ICU, and in the surgical ICU.

To enable a full coverage of the program core curriculum, the

critical care residents have to participate in the following programs:

First Year: The critical care resident has to spend one month in anesthesia. He/she has to take a one week course in ECMO and must pass a test to be certified as "ECMO Specialist." The trainee has to take a 1 day course in "Renal Replacement Therapy" and become adept at using an automated RRT (PRISMA).
An in-service regarding the operation of PICU Defibrillators, Pacemakers and other monitoring equipment will also be provided. Second Year: The trainee has to have a research project. An IRB approval to carry out the project must be obtained. IRB courses will be provided.
Third Year: The third year is primarily devoted to research. The critical care resident is not allowed to do any electives.

Scope of Training in Research

The trainee is expected to design, conduct and present his own research project starting in the first year and continuing through the entire program. The trainee may chose between clinical or basic laboratory research projects. He or she will be advised and supervised by qualified pediatric staff members in the conduct of research. Seminars will be given throughout the training program as well as a course in research methods.

The critical care residents spend one month during their first year developing their research concept and ideas, reviewing literature in the areas they are interested doing research in, and discuss their ideas with the faculty and researchers within the division. Occasionally, a clinical research proposal is established during this month. During the second year, the critical care resident has 3 months to set up the laboratory for his/her research or to obtain an IRB approval for their clinical research protocol. In the third year the critical care resident has 9 months of protected time to carry out his/her study, collect and analyze the data and write a manuscript.

The NSLIJ health system has a research building where most pediatric subspecialties can use a laboratory for basic research. Pediatric Critical Care uses a laboratory for basic research as well. The laboratory is set up as an operating room and, thus, allows the use of animal models in respiratory, cardiovascular and central nervous system physiology. The laboratory has all the equipment required for simple surgical procedures, mechanical ventilation and a blood gas analyzer. The resident can use the laboratories of other divisions for specific tests regarding his or her project. The critical care resident is provided with a list of existing models and other basic research topics, and together with his or her supervisor, a decision is made as to which research topic to pursue. A research proposal is written by the critical care resident and presented to the Critical Care Research Committee which includes the Director of Pediatric Critical Care and other PICU attendings, all residents of Pediatric Critical Care, the head of the research facility, and other researchers and lab technicians. The resident himself carries out the research under the supervision of a researcher. Clinical research is done in the PICU on patients, based on approved protocols. The critical care resident is responsible for all data collection, statistics and manuscript preparation. The research building is equipped with an animal facility operating room and recovery room. The Critical care laboratories are equipped with monitors, computers and all the supplies required to investigate cardiovascular pathophysiology electrophysiology, the central nervous system and the pathophysiology of electrolyte imbalance.

Daily activities of the Trainees

Trainee #1: Clinical coverage of multidisciplinary patients

This trainee assumes all clinical responsibilities for all patients in the PICU apart from the cardiothoracic surgical patients and patients on ECMO.

The critical care resident rounds with pediatric residents at 7:00AM during which he gets the opportunity to teach and help the residents with their data collection, presentation and documentation. He, also, helps them to develop a management plan for each patient in the PICU.

At 8:00AM the trainee #1 can join the cardiology, cardiovascular surgery and critical care joint rounds on all post-operative cardiac patients. His major contributions during these rounds are in mechanical ventilation, airway management, fluid and electrolyte balance, vasoactive drug administration and nutrition.

At 9:00AM the critical care resident (trainee #1) rounds with the PICU attending, together with the pediatric residents and nurses.

At 11:00AM the critical care resident participates in x-ray rounds with attendings in the Pediatric Radiology Department. All x-ray films of the PICU patients are reviewed and discussed.

Trainee #2: Clinical coverage of cardiothoracic surgical patients and patients on ECMO.

Post-cardiovascular surgical patients are admitted to the PICU.

A team composed of three subspecialties contributes to the care of

these patients:

A. Cardiothoracic Surgery
B. Cardiology
C. Critical Care

The critical care team includes the critical care resident and his or her attending. Daily rounds at 8:00AM include all three subspecialties. The critical care faculty has the overall responsibility for all cardiothoracic surgical cases admitted to the PICU. Their primary responsibilities are for issues regarding mechanical ventilation, fluid and electrolyte balance, vasoactive drug administration and nutrition.

Trainee #3: Back-up

This trainee will serve as back up to trainee #1 and #2. He or she will assume clinical responsibilities should the work load be too excessive for the trainees on service. He or she will, also, go on transport and transfer critically ill patients to the PICU from other outlying hospitals. This trainee will escort patients within the hospital to (CT/MRI, cath lab. etc) and will help in procedures (sedation, placement of central venous catheters etc.) for patients admitted to the other clinical units within SCH. When the trainee on service (#1 or #2) is post-call, trainee #3 assumes the responsibility for his/her patients.

Trainee #4: Research

This trainee is expected to do nothing else but research.

Trainee #5: Off

This trainee is after a night call and should leave the hospital

premises no later than 8:00 AM and rest. He/she should report back to the PICU not earlier than 8:00AM the next day.
Trainee #6 Transport

This trainee is enrolled in the Emergency Transport Program of

the Division. He/she does not take part in any clinical activities within the PICU. Their role is to stabilize, manage and transport pediatric critically ill patient from outlying hospitals to the PICU. This trainee is available by phone or pager from 4:00 PM until 8:00 AM, Monday through Friday. Their active patient care time should not
exceed 30 hours per 5 days (6 hours per day).

Core Curriculum

1. Resuscitation
A. Basic and advanced cardiopulmonary resuscitation
B. Central nervous system resuscitation

2. Cardiovascular physiology, pathology, pathophysiology,and therapy
A. Shock
1. Hypovolemic
2. Cardiogenic
3. Traumatic
4. Septic
B. Cardiac arrhythmias and conduction disturbances -pacemakers
C. Pulmonary embolism
D. Pulmonary edema - cardiogenic and noncardiogenic
E. Cardiac tamponade and other acute pericardial diseases
F. Acute valvular disorders
G. Cardiomyopathies and myocarditis
H. Management of post cardiac surgery patients
I. Management of congestive heart failure
J. Evaluation and management of congenital heart lesions
K. Vasopressor and/or vasodilator therapy and cardio- assist devices
L. Current concepts of Starling's Law of the heart and capillary circulation to include calculations and interpretation of hemodynamic parameters
M. Hemodynamic effects caused by ventilatory assistdevices
N. Myocardial ischemia/infarction
O. Kawasaki Disease
P. Cor pulmonale

3. Respiratory physiology, pathology, pathophysiology, and therapy
A. Acute respiratory failure
1. Hypoxic - adult respiratory distress syndrome
2. Hypercapnic
3. Neurologic, mechanical
B. Status asthmaticus
C. Smoke inhalation, airway burns
D. Aspiration, chemical pneumonitis, near drowning
E. Flail chest, barotrauma
F. Bronchopulmonary infections
G. Upper airway obstruction
H. Pulmonary function tests
1. Pulmonary mechanics
2. Respiratory adequacy - i.e. blood gases
I. Oxygen therapy
J. Hyperbaric oxygen
K. Mechanical ventilation
1. Pressure and volume ventilators
2. Positive end-expiratory pressure, intermittent mandatory ventilation, continuous positive airway pressure, pressure support, high frequency ventilation, etc.
2. Indications and hazards
L. Airway maintenance
1. Endotracheal intubation
2. Tracheostomy
3. Long-term intubation vs. tracheostomy
M. Bronchiolitis
N. Bronchopulmonary dysplasia - pulmonary fibrosis
O. Croup, epiglottitis, tracheitis
P. Home ventilation - indications/management
Q. Pulmonary abscess
R. Apnea
S. Subglottic stenosis/tracheomalacia
T. Cystic fibrosis

4. Renal physiology, pathology, pathophysiology, and therapy
A. Renal failure
1. Pre-renal
2. Renal

5. Post-renal
A. Derangements secondary to alterations in osmolality and electrolytes
B. Acute acid-base disorders
D. Principles of hemodialysis, peritoneal dialysis, CAVH

6. CNS physiology, pathology, pathophysiology, and therapy
A. Coma
1. Metabolic
2. Traumatic
3. Infectious
4. Mass lesions
5. Vascular-anoxic-ischemic
6. Overdose
7. Pentobarbital induced
B. Hydrocephalus
C. Congenital malformations
D. Status epilepticus/seizures
E. Meningitis/encephalitis
F. Increased intracranial pressure
1. Anoxic/hypoxic/ischemic
2. Traumatic
3. Mass occupying lesion/tumor
G. Head trauma
H. Spinal cord injury
I. Cerebrovascular disease
J. Hypertensive encephalopathy
K. Brain death
L. Reye's syndrome
M. Myopathies/neuropathies
N. Guillain-Barre syndrome
O. Myasthenia gravis
P. Intraventricular/intracranial hemorrhage

7. Metabolic and endocrine effects of critical illness
A. Colloid osmotic pressure
B. Alimentation
1. Enteral
2. Parenteral - hypertonic glucose, amino acids,lipids
C. Thyroid storm
D. Malignant hyperthermia
E. Adrenal crisis
F. Disorders of antidiuretic hormone - diabetes insipidus, syndrome of inappropriate secretion of antidiuretic hormone
G. Diabetes mellitus - diabetic ketoacidosis - hyperosmolar coma
H. Hypoglycemia
I. Inborn errors of metabolism
J. Pheochromocytoma
K. Disorders of calcium, magnesium, and phosphate metabolism
L. Heat stroke

8. Infectious disease physiology, pathology, pathophysiology, and therapy
A. Type of infection and therapy
1. Bacterial
2. Fungal
3. Viral
4. Tuberculous
5. Anaerobic
6. Parasitic
7. Rickettsial
B. Infection control and isolation
C. Prophylaxis
D. Systemic sepsis - mediators and intervention
E. Tetanus
F. Botulism
G. Opportunistic infections - AIDS
H. Nosocomial infections
1. Complicating endotracheal intubation
2. Complicating intravascular lines
3. Complicating intracranial monitors
4. Urinary tract
I. Adverse reactions to antimicrobial agents

9. Hematological and oncologic disorders - physiology, pathology, pathophysiology, and therapy
A. Acute defects in hemostasis
1. Thrombocytopenia
2. Disseminated intravascular coagulation
3. Primary fibrinolysis
B. Anticoagulation therapy
C. Principles of blood component therapy
1. Platelets
2. Packed red blood cells
3. Fresh frozen plasma
4. Specific coagulation factor concentrates
5. Albumin
6. White blood cells
D. Acute hemolytic disorders
E. Acute syndromes associated with neoplastic disease and/or antineoplastic therapy
F. Sickle cell crises
G. Hemophilia
H. Bone marrow transplantation
I. Acute anemia/aplastic anemia
J. Hemolytic uremic syndrome/thrombocytopenia purpura
K. Leukemia/lymphomas

10. Gastrointestinal - genitourinary acute disorders
A. Acute pancreatitis
B. Upper gastrointestinal bleeding
C. Lower gastrointestinal bleeding
D. Acute hepatic failure
E. Gastrointestinal obstruction/perforation/infarction
F. Ruptured viscus
G. Acute inflammatory diseases of the intestine
H. Stress ulcer prophylaxis and treatment
I. Urinary tract hemorrhage

11. Trauma - Burns
A. Management of multisystem trauma
B. CNS trauma - brain and spinal cord
C. Skeletal trauma including spine
D. Chest trauma
1. Blunt
2. Penetrating
3. Cardiac
E. Abdominal trauma
1. Blunt
2. Penetrating
3. Cardiac
F. Crush injury
G. Burns
1. Thermal injuries - pathophysiology
a. Estimation of burn size and depth
b. Physiology of fluid management
c. Wound management
d. Nutrition
e. Pain control
2. Inhalation injuries/airway burns
3. Carbon monoxide poisoning
4. Electrical injuries/lightning

12. Ingestions/overdose
A. General supportive therapy
B. Enhancement of elimination
C. Specific antidotes

13. Immunologic
A. General supportive therapy
B. B-cell/T-cell/combined immunodeficiencies
C. Anaphylaxis/angioneurotic edema

14. Monitoring, bioengineering, biostatistics
A. Prognostic indices and severity scores
B. Principles of ECG monitoring
C. Invasive hemodynamic monitoring
1. Transduction - principles of strain gage transducers
2. Signal conditioners, calibration, gain, adjustment
3. Display techniques
4. Principles - arterial, central venous, and pulmonary artery pressure monitoring
5. Assessment of cardiac function and derived hemodynamic parameters
D. Noninvasive hemodynamic monitoring
E. Thermoregulation
F. Brain monitoring - intracranial pressure monitoring, EEG, etc.
G. Respiratory monitoring - airway pressure, tidal volume, compliance, etc.
H. Metabolic monitoring - oxygen consumption, respiratory quotient, etc.

15. Sedation and pain control
A. Bolus vs. continuous infusion
B. Weaning from/withdrawal
C. Indications/adverse effects

16. Transport of the critically ill child

17. Pharmacokinetics and dynamics; drug metabolism and excretion in critical illness

18. Ethical and legal aspects in critical care medicine
A. Death and dying
B. Ordinary versus extraordinary life support mechanisms
C. Organ transplantation
D. Standards of treatment for handicapped and mentally retarded
E. The rights of patients/right to refuse treatment/proxy

19. Administrative and management principles and techniques
A. Guidelines for training physicians in pediatric critical care medicine
B. Organizing and staffing critical care units
C. Medical record keeping in special care units

Critical Care Medicine Skills

1. Airway
A. Maintenance of open airway in non intubated, unconscious, paralyzed patients
B. Intubation (oral, nasotracheal, tracheostomy, etc.)
2.Breathing, ventilation
A. Ventilation by bag and mask
B. Indications, applications, techniques, criteria, and physiological effects of positive end-expiratorypressure, intermittent positive pressure breathing,intermittent mandatory ventilation, continuouspositive airway pressure, etc.
C. Use of intermittent positive pressure breathing therapy, bronchodilators, humidifiers, entilatory
modes
D. Suction techniques
E. Chest physiotherapy
F. Fiberoptic laryngotracheobronchoscopy
G. Weaning techniques
H. Management of pneumothorax (needle, chest tube insertion, different drainage systems)
I. Operation of mechanical ventilators
J. Measurement of endotracheal tube cuff pressures
K. Interpretation of sputum cultures
L. Performance of bedside pulmonary function tests
M. Application of appropriate oxygen therapy
3. Circulation
A. Arterial puncture and blood sampling
B. Insertion of central venous, arterial, and pulmonary artery catheters
C. Pericardiocentesis
D. Transvenous pacemaker insertion
E. Cardiac output determinations
F. Dynamic ECG interpretation
G. Infusion of vasoactive drugs/recognition of complications
H. Cardioversion
I. Understanding use of intra-aortic assist devices
J. Understanding use of ECMO
K. Recognition and evaluation of hypertension
4. Central Nervous System
A. Lumbar puncture
B. Management of intracranial pressure monitors
C. Monitoring of modified EEG
5. Renal
A. Electrolyte balance
B. Calculation and interpretation of free water clearance
C. Interpretation of urine electrolyte analysis
D. Calculation and interpretation of creatinine clearance
E. Evaluation of oliguria/anuria
F. Differentiating pre-renal, renal, and post-renal failure
G. Instituting and managing peritoneal and hemodialysis, hemoperfusion, and hemofiltration
6. Gastrointestinal tract
A. Insertion of transesophageal devices (nasogastric, aerogastric, nasojejunal tubes, etc.)
B. Prevention and management of upper gastrointestinal bleeding
7. Hematology
A. Utilization of blood component therapy
B. Management of massive transfusions
C. Autotransfusion
D. Proper ordering and interpretation of coagulation studies
8. Infection
A. ICU sterility techniques and precautions/isolation
B. Sampling, staining, interpretation, etc. of blood, sputum, urine, drainage fluid samples
C. Interpretation of antibiotic levels, sensitivities, etc.
9. Metabolism/Nutrition
A. Tube feeding
B. Total parenteral nutrition
C. Monitoring and assessment of metabolism and nutrition (bedside metabolic cart)
D. Maintenance of temperature homeostasis
10. Monitoring/Bioengineering
A. Utilization, zeroing, calibration of transducers
B. Use of amplifiers and recorders
C. Trouble shooting equipment
11. Trauma
A. Temporary immobilization of fractures
B. Application of MAST trousers
C. Use of special beds
12. ICU Laboratory
A. Blood gas analysis
B. Calculation of oxygen content, intrapulmonary shunt, alveolar-arterial gradient
C. Recognition and therapy of respiratory and metabolic acidosis and alkalosis

Mandatory Courses and Assignments:

1. A course in research methods and data analysis

2. A 7 day course in ECMO treatment

3. A 1 day course in continuous V-V hemofiltration (PRISMA)

4. Sedation and analgesia:

1. A brief course + test in conscious sedation
2. A bedside training in deep sedation for patients undergoing procedures such as:
Heart cath.
Placement of vascular catheters
Placement of tubes for body cavity drainage
Bronchoscopy/endoscopy
Transesophageal echocardiography
CT/MRI/Radiation therapy

Evaluation of Trainees and Faculty

Evaluation of the fellows comprises an essential part of the educational process, and will be conducted during and at the end of the fellowship. The purpose of the evaluation should be to assess the fellow's knowledge, skills, and attitudes while functioning as a clinician, administrator, educator, and clinical investigator. This evaluation includes the following assessment:

1. Cognitive testing: assessment of the acquisition and integration of knowledge required for pediatric CCM by written tests.

2. Performance testing: demonstration of satisfactory performance compared with preset criteria of technical procedures commonly required in a pediatric intensive care unit.

3. Achievement: assessment of the fellow's overall performance as a clinician, educator, administrator,and investigator compared with the evaluator's expectations for the individual's level of training; this assessment should include the fellow's interpersonal skills, personal qualities, and recommendations by the faculty regarding specific areas in need of improvement.

In addition, fellows will be given the opportunity to evaluate the faculty with regard to the same kinds of criteria (knowledge, skills, and attitudes as clinicians, educators, administrators, and investigators) as well as personal attributes and relationships with others. Written records of the evaluations will be maintained in the departmental files. The Program Director will discuss the evaluation of the fellows during and at the completion of the fellowship, and provide the fellow with specific recommendations for correction of perceived deficiencies. The Program Director should also provide similar counsel to his faculty on the basis of their evaluations. Both the fellows and the faculty will receive the written summaries of these evaluations.

FELLOWS' CREDENTIALLING REQUIREMENTS for SPECIFIC PROCEDURES

1. The fellow should not perform any of the following procedures in or outside of the PICU, without supervision by a critical care attending, unless he or she has done the following specified number of supervised procedures:

*Endotracheal intubation: 3

*Arterial cannulation: 3

*Placement of central

venous catheters -

femoral: 3

subclavian: 3

ext. jugular: 3

int. jugular: 3

*Tube thoracostomy: 3

*Abdominal paracentesis: 3

*Hemofiltration: 3

*Pericardiocentesis: 10

*Pul. Art. catheterization 10

2. All fellows should be in compliance with the above guidelines.* These procedures can be performed unsupervised by the fellow in an emergency situation when a critical care attending is not readily available.

THE TRAINEES RESPONSIBILITIES IN THE PICU

ROUNDS ROUNDS

PROCEDURES PROCEDURES

DAILY NOTES DAILY NOTES

REPORTS TO ATTENDING REPORTS TO ATENDING

TRAINEE #3

BACK-UP TO TR#1 OR #2

TRAINEE #4

RESEARCH/ELECTIVE

TRAINEE #5

POST CALL-OFF

TRAINEE #6

TRANSPORT

THE TRAINEES RESPONSIBILITIES OUTSIDE THE PICU

TRAUMA

THE TRAINEE ON SERVICE (TRAINEE #1) AND THE TRAINEE ON CALL HOLD THE TRAUMA BEEPERS.

UPON TRAUMA TEAM ACTIVATION:· THE TRAINEE HOLDING THE TRAUMA BEEPER REPORTS TO THE E.D.· THE BACK-UP TRAINEE, IF AVAILABLE, ASSUMES RESPONSIBILITY FOR PATIENTS IN THE PICU

THE TRAINEE'S RESPONSIBLITIES IN THE E.D. SHOULD A TRAUMA PATIENT ARRIVE:· VASCULAR ACCESS· AIRWAY (IF ANESTHESIA IS NOT PRESENT)· INTRAHOSPITAL TRANSPORT (TO RADIOLOGY, PICU ETC.,) OF UNSTABLE PATIENTS· REPORTS TO CRITICAL CARE ATTENDING

THE TRAINEES RESPONSIBILITIES OUTSIDE THE PICU

CPR (CODE)

THE TRAINEE ON SERVICE AND THE TRAINEE ON CALL HOLD
THE CODE BEEPERS.

UPON ANNOUNCEMENT OF A CODE:· THE TRAINEE HOLDING THE CODE BEEPER REPORTS TO THE SITE.· THE BACK-UP TRAINEE ASSUMES RESPONSIBILITY FOR PATIENTS IN THE PICU

THE TRAINEE'S RESPONSIBILITIES DURING CODE:· AIRWAY· VASCULAR ACCESS· REPORTS TO THE "CAPTAIN" OF THE CODE· BECOMES THE "CAPTAIN" OF THE CODE IF NO OTHER MORE SENIOR PHYSICIAN IS PRESENT· INTRAHOSPITAL TRANSPORT (TO RADIOLOGY, PICU ETC.,)· REPORTS TO CRITICAL CARE ATTENDING
THE TRAINEE RESPONSIBILITIES OUTSIDE SCH

TRANSPORT

THE PICU TRANSPORT COORDINATOR RECEIVES
INFORMATION ABOUT PATIENTS REQUIRING TRANSPORT
TO THE PICU AND INFORMS TRAINEE/ATTENDING

RESPONSIBILITIES OF TRAINEE ON TRANSPORT SERVICE

· TO INFORM HIS/HER ATTENDING AND OBTAIN APPROVAL FOR TRANSPORT AND GENERAL INSTRUCTIONS.

· TO BE THE TRANSPORT TEAM LEADER.

· DURING WEEKENDS AND HOLIDAYS (WHEN A TRANSPORT FELLOW IS UNAVAILABLE) THE TRAINEE ON CALL MAY LEAVE THE PICU FOR TRANSPORT. HOWEVER, THIS NEEDS TO BE APPROVED BY THE CRITICAL ATTENDING.

· DURING NIGHTS AND WEEKENDS THE TRAINEE DOES NOT LEAVE THE PICU IF UNSTABLE POST OPERATIVE CARDIAC PATIENTS ARE IN THE PICU, UNLESS THE CARDIOLOGY FELLOW AND/OR THE CRITICAL CARE ATTENDING COME IN TO REPLACE HIM/HER.

· DURING NIGHTS AND WEEKENDS THE TRAINEE DOES NOT LEAVE THE PICU IF THERE IS A PATIENT ON ECMO, UNLESS A NEONATAL TRAINEE WHO IS A CERTIFIED ECMO SPECIALIST (BY SCH TRAINING) IS PRESENT IN THE HOSPITAL AND/OR THE CRITICAL CARE ATTENDING OR NEONATAL ATTENDING COME IN.

· THE TRAINEE ON TRANSPORT SERVICE ASSUMES FULL CPR AND GENERAL MANAGEMENT RESPONSIBILIITES ONCE THE TRANSPORTED PATIENT IS ON THE TRANSPORT STRETCHER. UNTIL THE TIME THIS OCCURS HE/SHE REPORTS TO THE PATIENT'S ATTENDING AT THE REFERRING HOSPITAL, IF PRESENT.

ESCALATION OF CALLS POLICY

In States of Emergency: The trainee is allowed to make decisions, do procedures and implement management plans as deemed appropriate by his/her judgment. Under these circumstances time should not be wasted to report or obtain approvals from pertinent attendings.

In All Other Situations: The trainee is required to inform his/her attending of any significant clinical development occurring in the PICU patients. The trainee should obtain an attending approval for invasive procedures, transport/transfer of patients, extraordinary medical management (exchange transfusion, dialysis, pharmacological coma or paralysis etc). For patients who are jointly managed with other disciplines, (ie Cardiology, Neurology, Neurosurgery, Surgery) the trainee has to inform the pertinent attendings or their trainees (fellows) of the aforementioned developments and his/her management plans.

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