Residency Subspecialty Education

The experience in pediatric critical care consists of a one month block rotation in the PL2 year in the PICU at KCHC. A second block rotation occurs in either the PL2 or PL3 year in the PICU at UHB or as a PL3 supervising senior in the PICU at KCHC. The residents are directly responsible for the evaluation, management, reassessment and care coordination for a diverse group of patients presenting with acute, severe medical illness, severe exacerbations or complications of chronic disease, post-surgical management (including neurosurgery, thoracic surgery and transplant surgery) and trauma. Residents are involved in every aspect of the critically ill patient’s care. Resident participation begins on initial presentation in the emergency room through the daily care, hourly monitoring, all procedures and interventions in the ICU, all communications with patients’ families, primary care providers and other members of the care team and preparation and planning for transfer, discharge and home care needs. Residents write all of the orders, admission notes, document daily progress, prepare discharge/transfer notes and consultation requests. Invasive procedures (e.g. intubation, central venous line placement, arterial line placement) are performed by residents under the direction of supervising attending faculty.

Through extensive patient contact, patient care experiences and formal didactic sessions given throughout the month, residents develop an understanding and appreciation for the multiorgan system and multidisciplinary aspects of pediatric critical care. Using faculty trained in critical care and subspecialty consultants residents develop an understanding and competency in the management of complex, life threatening conditions in children across a spectrum of ages. Particular emphasis is placed on nutrition (including TPN), fluid and electrolytes, cardiac management (including pressor support), respiratory management (including intubation and mechanical ventilation), CNS management (including ICP management, cerebral edema and shunts/drains), infection control ( including management of contagious disease and isolation precautions), sedation and pain management, invasive and non-invasive monitoring and support, laboratory data ,and psychosocial implications in critical illness. Basic and advanced life support protocols and techniques are reviewed and practiced. Residents have the opportunity to participate in transport of patients within the hospital and between hospitals or other care facilities. Pediatric residents also participate in the care and pre/post operative management of surgical patients and patients with multiple trauma. Patients with surgical subspecialty problems are cared for by the pediatric medical service in the PICU.

Upon beginning the PICU rotation, residents are given a pre-test to introduce them to concepts of management in the ICU setting. Toward the end of their rotation, a post-test is given to evaluate acquisition of knowledge and extent of practice-based learning. In addition to pediatric critical care specific knowledge and patient care skills, residents are expected to demonstrate practice based learning, appropriate communication skills, appreciation for and adherence to the highest ethical principles (often challenged in the ICU setting) and involvement in system based practice including appropriate risk management, performance improvement and quality assurance activities.

The Pediatric ICUs at KCHC and UHB are modern units capable of providing state-of-the-art sophisticated intensive care to a full and diverse spectrum of patients.

KCHC is a large, busy municipal facility serving an underprivileged inner-city population with a large immigrant community. KCHC has an extremely active emergency department and is a level I trauma center. The PICU at KCHC consists of a brand new 7 patient individual room unit including 2 negative pressure laminar flow isolation rooms in a technologically sophisticated new inpatient care tower. Each bed has capacity for monitoring a full range of invasive and non-invasive parameters along with central station monitoring. There is also a medical information computer workstation at each bedside. In addition, there are 4 close watch/step down beds on the inpatient unit which are co-monitored by the PICU. The unit has a consultation room, a bereavement room, a conference room, a large visitors lounge along with 2 available bedrooms for parents wishing to remain near their children overnight. All approved and standard of care treatment modalities are available including new microprocessor controlled multimodal ventilators, high frequency ventilation, heliox therapy, transcranial doppler and intracranial blood flow monitoring, external pacemaker support, hemo and charcoal perfusion and nitric oxide administration. A robotic pharmacy provides unit dosing and a digital imaging radiography system (PACS) is on-line. Computer stations throughout the unit provide access to medical record information as well as medical references and internet access to the College of Medicine and its online resources. The clinical pathology labs provide comprehensive services and microtechnique for pediatric samples.

UHB is a state operated tertiary care referral facility that also serves the primary care and acute care needs of nearby communities. UHB provides organ transplantation services, stem cell transplantation and hypertransfusion, oncologic services, neurophysiological monitioring, cardiac and cardiothoracic services, hemodialysis and peritoneal dialysis, an asthma and respiratory disease center and a variety of surgical subspecialty services including airway reconstruction, neurosurgical repair, genitourinary reconstruction, etc. Many of the patients receiving these sevices require PICU care. In addition, UHB receives acute admissions through a walk-in urgent care center and an ambulance receiving emergency room. The PICU at UHB consists of a 5-bed open floor plan ICU with one additional double door isolation room. There is a 4-bed step down unit available on the adjacent inpatient unit. This unit can provide plasmapharesis, hemodialysis, 24 hour digital EEG in addition to comprehensive standard monitoring, and all modalities of support and intervention identified for the KCHC PICU. The unit has access to a digitized imaging retrieval system, robotic unit dosing pharmacy and all internet resources. Point of care I-Stat testing is available and the clinical pathology laboratory provides microtechnique for pediatric samples.