Pulmonary & Critical Care Medicine Fellowship – Clinical Experience

Our Pulmonary/Critical Care Fellowship Program is a 3 year, ACGME certified training program that includes intensive instruction in clinical medicine. During their 3 years, our fellows will gain extensive experience with in-patient and out-patient pulmonary medicine as well as critical care training in ICUs that range from general community based to the highest-level tertiary care ICU in the region. Pulmonary education will include extensive exposure to pulmonary hypertension, interventional pulmonary, interstitial lung diseases, cystic fibrosis, advanced sleep disorders, pulmonary physiology, as well as general pulmonary diseases. Critical care training will give fellows experience in extracorporeal membrane oxygenation, state of the art ventilator technique, trauma critical care, neuro-critical care as well as general medical critical care. If desired, fellows can take extra clinical months for training in elective topics which can occur at our institution or at other institutions. Our program emphasizes competence at a wide variety of pulmonary and critical care procedures and our fellows typically graduate proficient in endotracheal intubations, pulmonary artery catheterization, chest tubes, and many advanced elements of interventional bronchoscopy including endobronchial ultrasound.

• Areas of Expertise

  Sepsis
  Our division has a long history of research into the causes and treatment of sepsis. Dr. Mitchell Levy has been a leader in the creation of international professional organization-based sepsis guidelines for over 20 years and the co-director of the Ocean State Clinical Coordinating Center, which manages large, multi-center international RCTs in sepsis. There is significant expertise in the division around developing protocols for large sepsis RCTs. We have also been involved in national and State-wide initiatives in sepsis performance improvement programs and are major contributors to the national SEP-1 mandated reporting with sepsis measures. In addition, we have been collecting samples for a sepsis and ARDS biobank for the past 6 years.

  Interventional Pulmonology
  We offer extensive training for the fellows in bronchoscopy and pleural procedures and have expanded our practice and training in interventional pulmonology. We are performing a variety of interventional bronchoscopic procedures including endobronchial ultrasound (EBUS), navigational bronchoscopy, endobronchial brachytherapy, electrocautery, and various biopsy techniques. In addition to these procedures, our fellows gain extensive experience with large and small chest tube placement.

  Pulmonary Vascular Diseases
  Rhode Island Hospital is an accredited as a Pulmonary Hypertension Comprehensive Care Center. Drs. Corey Ventetuolo, Christopher Mullin, and James Klinger lead a team that diagnoses and manages hundreds of cases each year as well as conducts significant bench and clinical research in the field. Fellows will work with them on several rotations and perform or assist in all right heart catheterizations and vasodilator trials done on these patients.
  In addition, Drs. Matthew Jankowich and Gaurav Choudhary (Cardiology) manage a multi-disciplinary Pulmonary Hypertension Clinic at the Providence VA Medical Center, performing right heart catheterizations and managing patients with primarily Group 2 and Group 3 Pulmonary Hypertension.

  Extracorporeal Membrane Oxygenation (ECMO) Program
  Along with members of the division of Cardio-thoracic Surgery our division runs the Rhode Island Hospital (RIH) ECMO service. RIH was recently accredited as an ECMO Center of Excellence, and this service provides care to patients in all ICUs who need this therapy for respiratory failure, cardiogenic shock, or other severe illnesses. We are one of the most active centers in our region and a major referral center. Our fellows will actively participate in the care of these patients in the medical ICU and have the opportunity for additional advanced training during their fellowship.

  Sleep Medicine
  Sleep medicine is a major part of the training of the Pulmonary Division. There is a separate Sleep Clinic which the fellows attend staffed by Sleep specialists. In addition, fellows have sleep training in the Pulmonary Clinic at the VA Medical Center. Fellows who want a more extensive experience in sleep medicine may elect to do research related to sleep disorders in their second year.

  Pulmonary Physiology Training
  Fellows interpret the various pulmonary function studies done in the laboratory including the results of spirometry, lung volumes, diffusing studies, arterial blood gases, cardiopulmonary exercise testing, bronchial inhalation challenges, and sleep studies. A pulmonary staff physician reviews the interpretation of the pulmonary fellow on a daily basis. Fellows participate in weekly physiology conferences to enrich their understanding of complex concepts related to lung physiology and pathophysiology.

  Pulmonary Clinic
  The fellow obtains longitudinal experience in the pulmonary and sleep ambulatory continuity clinics weekly held at both the Providence VA Medical Center and Rhode Island Hospital. An attending physician is an on-site preceptor while the fellow is seeing his or her patients.

  End of Life Care and Ethics
  Our division has been involved in multiple research projects for improving end of life care in the critically ill and improving communication for caregivers during end of life conversations. Dr. Nick Ward has a special interest in ethics and has also led several initiatives for physician/patient ratios in the ICU.

• Overview of Hospitals

  The Miriam Hospital
  The Miriam is a 247-bed, acute care general hospital in Providence and is a major teaching site for the Warren Alpert Medical School of Brown University. The ICU is a 16-bed, combined medical/surgical/cardiac unit which provides a very broad educational experience with an emphasis on collaborative rounds with these varied services. In addition to the medically ill patients critically ill cardiac patients are taken care of in this unit and provide extensive experience in cardiogenic shock, intra-aortic balloon pumps, hemodynamic monitoring, and pacing. Extensive experience with critically ill post-operative patients is also obtained here. The fellow’s pulmonary consult service covers all parts of the hospital which includes surgical services, a robust oncology services, and many medical services, all which provide diverse opportunities for trainee experience. An outpatient nodule clinic is run through the on-site cancer center to provide fellows more exposure to pulmonary nodule and oncology issues in the outpatient setting.

  

  Rhode Island Hospital
  A 721-bed tertiary care hospital with a broad spectrum of pulmonary and critical care diseases, it is the state’s largest hospital and the third largest hospital in New England. The 18-bed Medical Intensive Care Unit at Rhode Island Hospital (link) has a high turnover of acutely ill patients with multi-system failure and was recognized by the National Coalition on Healthcare as one of the ten best in the country. It serves as a referral center for many hospitals throughout southern New England and is an ECMO center of excellence. Our MICU serves as the intensive care unit for Womans & Infants hospital, which provides the fellow with important experience with critically ill obstetric patients. There are numerous other specialty critical care units staffed by specialists in other divisions that provide elective opportunities as well, including a cardiothoracic ICU, neurology/neurosurgery ICU, trauma, surgical ICUs, and a coronary care unit. Our division also staffs a respiratory intermediate care unit that manages complex respiratory patients as well. The fellow’s pulmonary consult service covers all parts of the hospital and is generally a busy service with many opportunities for procedural experience and complex patient management. The longitudinal fellow’s pulmonary clinic is located in an ambulatory center here, which all fellows will attend every other week during training.

  

  Providence VA Medical Center
  The VAMC of Providence is a 100-bed teaching hospital staffed by internal medicine residents from all of the Warren Alpert Medical School of Brown University affiliated programs. The pulmonary fellow is responsible for all ICU admissions, oversees an active consultation service with consults from the Medical, Surgical, and Psychiatric services, actively participates in a robust Lung Cancer Screening Program, and performs all pulmonary procedures including EBUS bronchoscopy. The VA system offers a unique educational experience for the pulmonary fellow by providing an environment with autonomy in decision making and a large number of patients with a variety of lung diseases willing to participate in clinical research. Critically ill patients are cared for in the recently constructed 9-bed Medical Intensive Care/Coronary Care/Surgical Intensive Care Unit. The pulmonary fellow makes daily rounds in this ICU. The VA Medical Center has a large ambulatory pulmonary service and fellows attend a once-a-week clinic as part of their longitudinal experience of outpatient pulmonary care.