Surgicalcriticalcare.net

The ACGME-accredited Surgical Critical Care Fellowship at Orlando Regional Medical Center has been internationally recognized since its inception in 1997. Our fellows receive state-of-the-art training in patient resuscitation and management as well as intensive care unit & trauma center administration, research, evidence-based medicine guideline development, statistical analysis, and quality improvement. Many of our fellows now direct intensive care units and trauma centers around the world.

Why Surgical Critical Care?

Today, an increasing proportion of patient care and hospital resources revolves around the Intensive Care Unit (ICU). Intensivist-led models of ICU care have been shown to improve patient outcome while simultaneously reducing costs. Hospitals and universities nationwide are recruiting well-trained surgical intensivists to direct such care. As a result, the Surgical Critical Care Fellowship at Orlando Regional Medical Center (ORMC) focuses not only on the clinical practice of intensive care, but also on ICU administration, quality improvement, and resource utilization. Our didactic program emphasizes multidisciplinary, state-of-the-art patient care, clinical research, evidence-based medicine guideline development, cost-containment, and database-driven process improvement. This comprehensive approach to patient care, academic productivity, and ICU administration ensures that our graduates are well prepared to effectively lead an ICU program.


Overview

The Surgical Critical Care Fellowship program at Orlando Regional Medical Center is an American Council for Graduate Medical Education (ACGME) accredited 12-month residency program that is intended to prepare graduates for a career in either academic or private practice surgical critical care. The educational philopsophy of the program is to provide a comprehensive matrix upon which to:

  • Develop a scientifically sound, evidence-based medicine approach to cost-effective management of the critically ill patient using the latest technologies and innovations,
  • Facilitate interpersonal skills in physician-patient and physician-family communication especially with regards to end-of-life and other ethical issues,
  • Promote effective and productive teaching abilities,
  • Encourage and develop intensive care unit leadership and hospital administrative skills, and
  • Foster an interest in and aptitude for scientific research, statistics, and critical thinking.

Each fellow is trained according to the recommended guidelines set forth by the Society of Critical Care Medicine to ensure a comprehensive exposure to all aspects of critical care practice. Our ultimate goal is to fully prepare our graduates to be not only superb clinicians, but also excellent academic teachers and thought leaders in their future institutions.

The Surgical Critical Care Residency is based at Orlando Regional Medical Center (ORMC), the 804-bed flagship hospital of a nine-hospital not-for-profit comprehensive healthcare system ("OrlandoHealth") that serves the needs of patients throughout Central Florida as well as millions of tourists each year. Orlando Regional Medical Center has served as the regional Level I Trauma Center and Burn Center for almost 20 years and currently provides trauma care for 22 different counties. With the Arnold Palmer Women and Children's Hospital and Charles Lewis / Orlando Health Cancer Center, ORMC serves as a state-of-the-art tertiary referral center providing Central Florida with a full range of medical services.

Prerequisites for Acceptance

The program accepts three (3) fellows per academic year. The prerequisites for acceptance to the program include: completion of an accredited graduate educational program in the disciplines of general surgery, neurosurgery, urology or obstetrics/gynecology OR completion of at least 3 clinical years in such a program with a categorical residency position to return to upon completion of the surgical critical care program. Please note that residents in preliminary positions do not meet these requirements.

Surgical Critical Care Residency Program Highlights

  • Over 3000 intensive care unit (ICU) admissions per year
  • ACS-verified Level I Trauma Center with over 6000 trauma admissions per year
  • ABA-verified Burn Center
  • One night call per week
  • 16-bed Trauma ICU
  • 16-bed Multidisciplinary Surgical-Medical ICU
  • 16-bed Neurosciences ICU
  • 16-bed Cardiac ICU
  • Web-based multimedia educational teaching program
  • Computerized bronchoscopy and ultrasound simulators
  • State-of-the-art hemodynamic monitoring
  • Active research program
  • Instruction in ICU and trauma center administration and quality assurance/improvement
  • Advanced Trauma Life Support (ATLS) Instructor training
  • Fundamental Critical Care Support (FCCS) Instructor training
  • Competitive salary and benefits

Educational Curriculum

Our comprehensive educational program in surgical critical care begins with an initial twelve-week lecture series by the critical care faculty addressing the "basics" of critical care management. The concepts introduced are reinforced at the patient bedside during daily patient teaching rounds. Following the initial lecture series, we begin to focus on developing the resident's advanced clinical skills as well as administrative skills and scholarly pursuits. Bimonthly evidence-based medicine guideline development working conferences are alternated with monthly research conferences and monthly "Professional Development" lectures. These advanced skills conferences are in addition to a weekly critical care lecture series, which addresses a variety of critical care topics throughout the year.

Each fellow, upon completing the residency, is expected to be able to demonstrate the folowing skills:

  • Demonstrate ability to organize and lead a comprehensive, multi-disciplinary approach to patients with multi-system critical illness.
  • List the indications, complications, and various techniques for monitoring the following:
    • arterial, central venous, and pulmonary arterial pressure
    • invasive and non-invasive cardiac output
    • continuous right heart volumetric measurements
    • intracranial pressure (ICP)
    • intra-abdominal pressure (IAP)
    • abdominal perfusion pressure (APP)
    • continuous pulse oximetry (SaO2)
    • continuous end-tidal capnography (PetCO2)
    • ventilator waveforms (flow-volume and pressure-volume loops)
  • Define in physiologic terms the adequacy of cardiac output and its implications for cellular oxygenation, end-organ perfusion, and multiple-system organ failure.
  • List and prioritize means for increasing cardiac output and oxygen transport through use of resuscitative fluid and vasoactive medication interventions.
  • Reproduce and effectively utilize the formulae for: mean arterial pressure (MAP)
    • mean pulmonary artery pressure (MPAP)
    • systemic vascular resistance index (SVRI)
    • pulmonary vascular resistance index (PVRI)
    • left ventricular stroke work index (LVSWI)
    • right ventricular stroke work index (RVSWI)
    • cardiac index (CI)
    • stroke volume index (SVI)
    • right ventricular end-diastolic volume index (RVEDVI)
    • coronary perfusion pressure (coronary PP)
    • cerebral perfusion pressure (cerebral PP)
    • abdominal perfusion pressure (APP)
  • List the major risk factors for and definitions of acute respiratory failure, acute lung injury, and acute respiratory distress syndrome (ARDS).
  • Discriminate between oxygenation, ventilation, and airway support.
  • Demonstrate proficiency in the various techniques for airway support.
  • List the physiologic mechanisms responsible for arterial hypoxemia and arterial hypercarbia including intrapulmonary shunt and deadspace ventilation.
  • Discuss indications, contraindications and complications of various modes of mechanical ventilation including: controlled mechanical ventilation (CMV)
    • intermittent mandatory ventilation (IMV)
    • assist control ventilation (ACV)
    • pressure support ventilation (PSV)
    • continuous positive airway pressure (CPAP)
    • bi-level positive airway pressure (BiPAP)
    • positive end-expiratory pressure (PEEP)
    • pressure controlled ventilation (PCV)
    • pressure controlled inverse ratio ventilation (PC-IRV)
    • independent lung ventilation (ILV)
    • high frequency ventilation (HFV)
    • airway pressure release ventilation (APRV)
  • Discuss various methods for supporting oxygenation in patients with arterial hypoxemia.
  • Reproduce and effectively utilize the formulae for:
    • arterial O2 content (CaO2)
    • venous O2 content (CvO2)
    • alveolar O2 content (CAO2)
    • alveolar O2 tension (PAO2)
    • intrapulmonary shunt (Qsp/Qt)
    • arteriovenous oxygen content difference (C(a-v)O2)
    • oxygen utilization or extraction ratio (VO2 / DO2)
    • oxygen delivery (DO2)
    • oxygen consumption (VO2)
  • Define and list the major categories of shock and recognize the hemodynamic patterns of each.
  • Select and administer appropriate resuscitation fluids for critically ill patients.
  • Appropriately define, recognize, and treat sepsis, septic shock, and systemic inflammatory response syndrome.
  • Interpret arterial blood gas measurements in terms of acid-base disorders, adequacy of oxygenation, and adequacy of ventilation.
  • List the differential diagnosis of oliguria and its appropriate management.
  • Identify laboratory tests that discriminate between intrinsic renal and pre-renal causes of oliguria and apply this information in the prevention of acute renal failure.
  • Demonstrate understanding of the importance of adequate nutrition in the critically ill and the various methods by which nutrition can be supported.
  • Discuss methods for prophylaxis against acute upper GI bleeding in acutely stressed patients.
  • Discuss non-pancreatic organ system dysfunction associated with acute pancreatitis.
  • Discuss the changes in biochemical markers associated with acute hepatobiliary dysfunction.
  • Identify and use screening tests available for the evaluation and treatment of coagulation disorders.
  • Identify and manage the presence of adrenal insufficiency of critical illness.
  • Demonstrate understanding of the unique physiology and complications of pregnancy.
  • Identify the differences between adult and pediatric resuscitation and critical care management.
  • Demonstrate proficiency in the assessment and treatment of thermal and electrical burns.
  • Discuss ethical considerations created by the use of modern technology and demonstrate ability to effectively and compassionately discuss end-of-life issues with patients and their family.
  • Demonstrate ability to develop educational programs and effectively teach the principles of critical care to other physicians and allied health personnel.
  • Demonstrate proficiency in research design, biostatistical analysis, and quality assurance programs that contribute to optimal patient care.

Frequently Asked Questions (FAQ)

"Is this a "fellowship" or a "residency"? What is the difference?"

Post-graduate training, including that in surgical critical care, is frequently referred to as a "fellowship". As this training program is accredited by the Residency Review Committee (RRC) of the ACGME, it is officially termed a "residency". For all intents and purposes, the two terms are synonymous in this setting and are used interchangeably.

"I have completed two years of surgical training. Can I apply to the residency?"

No. The ACGME requires that each applicant has either completed an ACGME-accredited residency program in general surgery, neurosurgery, urology, or obstetrics/gynecology OR completed at least three (3) years of clinical training with a categorical position to return to in their respective specialty upon completing the surgical critical care residency program.

"I completed a general surgery residency several years ago and am board-certified. Can I apply to the residency?"

Yes. In fact, a number of board-certified general surgeons have completed the residency program in recent years to either gain further knowledge and experience to improve their patient care or as a means to redirect their surgical career.

"Will I be able to operate during the surgical critical care residency?"

The ACGME requires that no more than 25% of the residency time be devoted to direct operative care. We consider this residency to be "non-operative" in that the surgical critical care residents do not have operative responsibilities outside of the critical care unit. The residency is oriented to promote the development of advanced skills in the diagnosis and management of the critically ill, using the latest technology, instrumentation, and medications. This advanced knowledge and expertise in clinical patient care, unit administration, and research activity comes at the price of not operating for at least eleven months of the residency. The residents do perform bedside tracheostomies and endoscopic procedures on a regular basis as part of their routine patient care. Occasionally, they may assist the general surgery faculty or residents with emergent bedside abdominal decompression in the critical care unit. The residents may elect to spend one of their two elective months rotating on either the Trauma Team or Burn Service where they would participate in scheduled operative procedures.

"What is the call schedule? How many hours per week will I be working"

The call is generally five nights per month and shared with general surgery and emergency medicine residents. Each fellow has at least one day off each week and one to two weekends off each month without clinical responsibilities. There is no "at-home call" at any time. The ACGME 80-hour per week resident duty hours requirement is strictly followed. While on call, a designated call room is available as are a resident's lounge and physician's dining room.

"What are the ancillary services like?"

The ancillary support services at ORMC are excellent. The surgical critical care residents are not required to start peripheral intravenous lines, draw blood, transport patients, or perform other roles or procedures that could be construed as being "non-educational". · These support services include: In-house surgical / trauma attending faculty 24/7; dedicated Doctor of Pharmacy specializing in surgical critical care; full-time surgical critical care research coordinator; In-house attending radiologists and radiology technicians (including ultrasound, computerized tomography and magnetic resonance imaging) 24/7; experienced respiratory therapy department; bedside echocardiography 24/7; intravenous line team 24/7; Wound Management team; Nutritional Support team.

"How are the residents evaluated?"

Each trainee receives a formal one-on-one evaluation quarterly from the program director in addition to informal discussions as indicated. The evaluation of the resident's performance consists of comprehensive rotation specific evaluations by the faculty and 360 degree evaluations performed by the ICU nursing and respiratory therapy staff. The resident and program director discuss the resident's progress, clinical and diagnostic skills, technical skills, didactic knowledge, problem-solving ability, judgment, and intra-personal skills as necessary. All patient care and procedures performed by the surgical critical care residents are documented online. As a result, patient and procedure lists can be viewed and printed by the program director and resident at any time to review and monitor the resident's experience and training. The results of the annual Multidisciplinary Critical Care Knowledge Assesssment Program (MCCKAP) exam are discussed with each resident as they become available from the Society of Critical Care Medicine. Each surgical critical care resident completes an evaluation of each critical care faculty member on a quarterly basis or following each elective rotation, which is reviewed by the program director. Issues raised are discussed with the faculty members, as necessary, on an anonymous basis.