Clinical training in the Pulmonary and Critical Care Medicine fellowship at the University of Pittsburgh and UPMC takes place over the first 18 months of the program. In that time frame, fellows complete 3-4 months of MICU critical care at UPMC Presbyterian Hospital and 2 months at UPMC Shadyside Hospital, 2 months of inpatient consults at UPMC Presbyterian, 2 months of combined critical care and consultation at the VA Pittsburgh Heath System (VAPHS), 2-3 months of Lung Transplantation (split between inpatient and outpatient experiences), 1 months in the outpatient Comprehensive Lung Center (CLC), 2 weeks of Inpatient Advanced Lung Disease, and 3 months of non-medical critical care, including the cardiothoracic ICU (CTICU). Rotations are 4 weeks in duration. Continuity clinic occurs one half day per week throughout the fellowship. See below for specific details regarding each rotation.
Critical Care Training
UPMC Presbyterian Medical Intensive Care Unit
The Medical Intensive Care Unit comprises 32 beds in a 792-bed tertiary referral center for patients with complex medical critical illness. Diseases diagnosed and managed on this service include respiratory failure (ARDS, pneumonia, COPD, asthma, or neuromuscular diseases); shock (distributive, cardiogenic, hypovolemic, or obstructive); gastrointestinal hemorrhage; major pulmonary embolism; congestive heart failure; acute and chronic renal failure; severe pancreatitis; hepatic failure; life-threatening infection; acute cerebral infarction, intracranial hemorrhage, and status epilepticus. In addition, the MICU provides critical care services for the UPMC Toxicology Program, which admits patients with a wide range of toxic ingestions and/or overdoses.
Patients in the MICU are cared for by two PACCM Faculty/Fellow partners and four house staff teams, each consisting of one resident and one intern. Fellows closely supervise the management of critically ill patients by the medical house staff and also gain extensive experience in critical care ultrasonography, airway management (including endotracheal intubation), mechanical ventilation, central venous and arterial catheterization, hemodynamic monitoring, pleural catheter and thoracostomy tube insertion, and bronchoscopy.
A paid moonlighting opportunity is available for fellows in the UPMC Presbyterian Medical ICU. Fellows who elect to participate will do four, 5-night blocks in the first year and sporadic nights throughout the second and third-year clinical and research months.
The MICU participates in numerous clinical research endeavors in the areas of ARDS, sepsis, ventilator-associated pneumonia, and functional and cognitive outcomes.
UPMC Shadyside Medical Intensive Care Unit
The teaching service at UPMC-Shadyside consists of 15-21 patients, who are cared for by one attending physician, one fellow, and eight residents. Fellows care for patients with a wide variety of critical illnesses, many of whom have complications related to a hematologic or solid malignancy. Fellows supervise and direct the care provided by the house staff and gain additional experience with endotracheal intubation, central venous and arterial cannulation, bronchoscopy, and pleural catheter and thoracostomy tube insertion.
Non-Medical Critical Care
Fellows receive 12 weeks of training in non-medical critical care including a 4-week rotation in the UPMC Presbyterian Cardiothoracic ICU (CTICU). The CTICU provides care for adult cardiac, thoracic, and vascular surgery patients, including those immediately following heart/lung transplantation. Experience in the acute post-operative management of cardiothoracic and thoracic surgery patients is the key focus of this rotation. In addition to traditional critical care procedures, fellows gain experience with extracorporeal membrane oxygenation and ventricular assist device support. The fellow assumes a primary management role on the CTICU team working closely with Critical Care Medicine faculty support.
For the remaining 8 weeks, fellows may choose either 2- or 4-week rotations in a variety of different ICUs. In the UPMC Presbyterian Neurovascular ICU, the fellow cares for critically ill patients with neurologic or neurosurgical disorders of vascular origin including acute cerebral infarction and hemorrhage, subdural hemorrhage, subarachnoid hemorrhage, status epilepticus, CNS malignancies, and intracranial hypertension.
The UPMC Presbyterian Trauma and Neurotrauma ICUs provide care for critically ill patients following major trauma, including traumatic brain injury. The Level 1 trauma program at UPMC is an integral component of one of the nation’s finest emergency and critical care networks. The Center for Emergency Medicine at the University of Pittsburgh directs one of the largest and most comprehensive air medical transport programs in the United States, and the City of Pittsburgh’s Department of Public Safety centers its Medical Command facility at UPMC Presbyterian Hospital. During this rotation, working closely with the trauma critical care faculty, the fellow gains experience in the multidisciplinary care of patients with complex multi-organ trauma.
Fellows may also work in the Transplant ICU, which specializes in the care of patients with post-transplant complications, or in the burn unit at UPMC Mercy Hospital.
Pulmonary Medicine Training
UPMC Presbyterian Consultation Service
The consultation service provides comprehensive diagnostic and therapeutic expertise for inpatients at UPMC Presbyterian and Montefiore Hospitals with simple or complex pulmonary disorders and education for the medical house staff and students. Examples of diseases diagnosed and managed on this service include COPD, asthma, pulmonary embolism, pulmonary hypertension, pulmonary vasculitis, pneumonia, pleural effusion, pneumothorax, interstitial lung disease, occupational lung disease, drug-induced lung disease, thoracic malignancies, and sleep-disordered breathing. Fellows evaluate all new consults and provide recommendations for the primary care team, follow-up relevant disease management on existing consult patients, perform all relevant diagnostic or therapeutic pulmonary procedures, oversee and manage teams consisting of medical house officers and students, and participate in educational efforts for the team.
Lung Transplant Service
The lung transplant service provides consultative care for advanced lung disease patients who are being evaluated for or are actively listed for transplantation in both the inpatient and outpatient settings. In addition, the transplant team provides primary inpatient and outpatient care for patients who have undergone lung or heart-lung transplantation.
In the pre-transplant setting, fellows learn the criteria for consideration for lung transplantation for a variety of advanced lung diseases, the detailed evaluation required of transplant candidates, and the organ allocation process. In the post-transplant setting, fellows are trained to manage a variety of immunosuppressive medications and to evaluate and manage various complications of transplantation, including acute and chronic organ rejection, opportunistic infections, post-transplant lymphoproliferative disease, and numerous drug toxicities.
Finally, this service also provides the fellow with extensive experience with both diagnostic and interventional bronchoscopy.
Inpatient Advanced Lung Disease/Medical Step Down
PACCM faculty staff a 36-bed respiratory care unit, which is split between inpatient lung transplant patients and patients with advanced lung disease. PACCM fellows may elect to round on the advanced lung disease service with PACCM faculty and advanced practice nurses. On this rotation, fellows gain experience managing patients with advanced lung pathology, including COPD, acute exacerbations of idiopathic pulmonary fibrosis, interstitial lung disease associated with collagen vascular disease, cystic fibrosis, and pulmonary hypertension. In addition, fellows gain experience implementing and managing non-invasive ventilation for patients with severe sleep disordered breathing or advanced neuromuscular disease.
Comprehensive Lung Center (CLC)
As with many internal medicine subspecialties, pulmonary medicine is primarily an outpatient discipline. The UPMC Comprehensive Lung Center (CLC) is a recently renovated 20,000 sq ft facility housing 20 individual patient examination rooms, a pulmonary function laboratory, and a pulmonary rehabilitation program. Specialists in the CLC see over 15,000 patients each year providing general pulmonary and consultative care for patients with all spectra of lung disease, including asthma, COPD, pulmonary hypertension, sleep disordered breathing, pulmonary hypertension, cystic fibrosis, and interstitial lung diseases, including pulmonary fibrosis, sarcoidosis, rheumatologic-associated lung disease, and hypersensitivity-induced lung disease. In addition, UPMC operates one of the busiest and most aggressive lung transplant programs in the world. The CLC provides outpatient pre-transplant evaluations and post-transplant care for patients with advanced lung disease from all over the world.
The CLC is the principle venue for the continuity clinic experience through fellowship training. In addition, fellows spend one month in the CLC during their first year, rotating through the many different subspecialty clinics. Fellows may also elect for an additional focused outpatient experience in the second year of training.
VAPHS Pulmonary Medicine Clinic
The VAPHS outpatient clinic serves as a referral center not only for the Oakland facility, but also for five other nearby VA Hospitals. The size of the clinic is carefully controlled to provide optimal patient care and teaching. Fellows see patients one-half day every other week throughout the first two years of training.
Combined Critical Care and Pulmonary Medicine Training
VA Pittsburgh Health System MICU/Consultation Service
The VAPHS MICU service cares for critically ill medical patients who have been admitted through the Emergency Department or referred from an outlying VA or non-VA facility. PACCM fellows are primarily responsible for managing the care of critically ill MICU patients and performing or supervising medical house officers with all procedures in conjunction with a PACCM faculty member. In addition, fellows provide pulmonary consultation services for patients throughout the hospital. Fellows gain experience evaluating and managing a wide variety of pulmonary and critical care disorders including ARDS, shock, pneumonia, COPD, asthma, bronchogenic carcinoma, pulmonary embolism, pulmonary hypertension, pleural effusion, pneumothorax, interstitial lung disease, occupational lung disease, drug-induced lung disease, and sleep-disordered breathing.
Fellows supervise the care provided to both MICU and consult patients by the medical house staff. They gain experience with critical care ultrasound, airway management, mechanical ventilation, and hemodynamic monitoring and perform all inpatient and outpatient bronchoscopies. In addition, the VAPHS houses a state-of-the art simulation center to assist with procedural training, including central line placement, bronchoscopy, and endobronchial ultrasound.
Additional Clinical Training Elective Opportunities
Long Term Acute Care
PACCM faculty staff Select Specialty Hospital, which is a 32-bed long-term acute care facility (LTACH) housed within UPMC Montefiore Hospital. Fellows may elect to rotate on this service, where they gain experience with management of chronic critical illness with a specific focus on chronic respiratory failure and tracheostomy management.
Senior fellows interested in gaining exposure to advanced bronchoscopic and pleural techniques can elect to rotate on an interventional pulmonology elective. This includes rotating through the bronchoscopy lab at UPMC Presbyterian where volume exceeds 1700 cases per year with approximately 15% involving advanced techniques, the VA Pittsburgh Bronchoscopy lab and the Hillman Cancer Center. Fellows will get exposure to advanced diagnostic bronchoscopic techniques including endobronchial ultrasound, navigational bronchoscopy and robotic bronchoscopy as well as therapeutic interventions utilizing flexible and rigid bronchoscopy with balloon dilation, self-expanding metallic and silicone airway stent deployment, laser and argon plasma ablation, cryotherapy, as well as advanced endoscopic COPD therapies including lung volume reduction using endoscopic valves, bronchial rheoplasty for chronic bronchitic phenotype COPD, and targeted lobar denervation. Fellows will also get training and exposure to ultrasound guided pleural procedures including thoracentesis, pigtail and surgical chest tube placement, indwelling pleural catheter placement, use of intra-pleural lytic therapy, and medical thoracoscopy.
Multidisciplinary Lung Cancer
The multidisciplinary lung cancer rotation is designed for fellows to gain experience with approaches to diagnosis and management of lung cancer. Fellows will spend time with lung cancer specialists in pulmonology, pathology, medical oncology, and thoracic surgery. In addition, fellows will attend tumor board on both the Presbyterian and Shadyside campuses.
PACCM Fellows may elect to spend dedicated time in the cardiac catheterization lab with expert pulmonary hypertension specialists to investigate pulmonary vascular hemodynamics at rest and with confrontational exercise testing. With this elective, fellows will obtain procedural experience with arterial line and pulmonary artery catheter placement, as well as interpretation of complex physiology with simultaneous cardiopulmonary exercise testing and invasive measurement of pulmonary vascular and cardiac function in association with upright cycle ergometry (iCPET) via the Advanced Cardiopulmonary Exercise Testing Program (ACPET). Invasive exercise testing helps to delineate disease states related to pulmonary arterial or venous disease, cardiac valvular disease, loading dynamics, and autonomic or skeletal muscle pathophysiology that limit exercise capacity as well as providing multidisciplinary and comprehensive investigation of dyspnea and exercise limitation for clinical and research purposes.
Fellows may elect to spend two weeks with expert attending chest radiologists and lung pathologists reviewing and interpreting studies and test results.
Fellows may elect to pursue critical care ultrasound certification by focused education and hands-on image training with an expert faculty member.
Dr. Lamberty‘s Ultrasound website: http://paccmus.com/wp/
Fellows rotating on the Thoracic Surgery service will be exposed to endobronchial ultrasound, CT-guided thoracic procedures, video-assisted thoracic surgery, and open chest surgery including lung transplantation. Fellows will gain experience with tube thoracostomy and bedside tracheostomy placement.
Lung Cancer/Interventional Bronchoscopy
Senior fellows interested in gaining exposure to advanced bronchoscopic techniques may elect to participate in interventional cases with our various faculty experts. Bronchoscopy volume at UPMC Presbyterian exceeds 1700 cases per year with approximately 15% involving advanced techniques including balloon dilation, laser ablation, cryotherapy, super-dimension, endobronchial ultrasound, and non-surgical lung volume reduction coil deployment. Additional experience with advanced bronchoscopy may be explored through rotation in the lung cancer program at UPMC Shadyside Hospital.
Magee Women’s Hospital
Magee-Womens hospital is a general medical and surgical hospital which houses the bariatric surgery program and a busy joint replacement practice. Magee is also the primary center for obstetrical and gynecologic care in the UPMC Health System and was rated #4 nationally for gynecologic care by US News and World Report in 2013. PACCM fellows provide consultative care for inpatients with a wide variety of pulmonary diseases. During this rotation, special emphasis is placed on the evaluation and management of patients with lung disease related to pregnancy or gynecologic disorders.