Critical Care Fellows Research Articles

Emergency medicine (EM) surgical critical care (SCC) trained physicians offer many advantages to SCC. However, several fields of critical care (CC) compete with SCC for EM intensivists. We hypothesized that there are definable and potentially modifiable factors related to the pathway selection. Cross-sectional survey. Four national EM societies. EM trainees (residents and fellows). None. The primary outcome included the top factors leading to pathway selection. Secondary outcomes included influential factors for entering CC and individual components of a CC fellowship that interest the EM trainee. One hundred eleven EM trainees responded-42 fellows and 69 residents. Median age was 32 (interquartile range, 30-35). Sixty-seven were matched (fellows + matched residents). Intended fields of practice: 49 anesthesiology CC (26 matched), 58 medicine CC (29 matched), two neurology CC (1 matched), six resuscitation (one matched), 15 SCC (eight matched), and five non-CC (two matched). Top factors for pathway selection included exposure to specialty units, geography and specialty multidisciplinary teams (p < 0.05). Ease of board certification was not influential. Only 28% of trainees had exposure to EM-SCC fellowships at their residency institution and only 42% had exposure to surgical intensivists during training. However, 41% envisioned practicing in a surgical ICU. Before application season, 8.2% did not have exposure to a surgical ICU/trauma ICU/trauma service that managed their ICU patients in contrast to the 3.2% of applicants not having medical ICU exposure. The highest-ranking factor for entering CC was intellectual appeal over job opportunities and lifestyle (p < 0.05). When assessing components of individual fellowship programs, CC knowledge, the institutional value of EM/critical care medicine, and extracorporeal membrane oxygenation exposure ranked highly. Given the complexity of the modifiable barriers for EM-SCC matriculation, a multifaceted approach is necessary to increase matriculants. Interventions specific to the specialty are required at professional societal, institutional, and training program levels.

Gastroesophageal Balloon Tamponade Simulation-Based Mastery Learning Curriculum for Critical Care Fellows.

BackgroundEscape Rooms in medical education have been shown to improve learner satisfaction and reinforce knowledge in pulmonary and critical care medicine, yet virtual escape rooms (VER) as instructional strategies have remained understudied.ObjectiveWe aimed to evaluate participants’ perception and knowledge acquisition after completing a VER as part of a national fellows’ course.MethodsWe designed a prospective study conducted during the 2022 CHEST Pulmonary and Critical Care Medicine Fellow's Virtual course. This was a 2-day back-to-back national course targeting pulmonary and critical care fellows. The course had 5 virtual and 1 VER session, each lasting 50 min. A pre- and post-course knowledge assessment included 9 clinical questions (1 for each of the 5 virtual sessions and 4 for the VER session). A summative score and an individual session score were obtained. Participant's VER perceptions were analyzed using a 5-point Likert scale (1 = strongly disagree and 5 = strongly agree).ResultsFifty-nine (34.5%) of the 165-course participants completed the pre-test, and 29 (17.8%) completed the post-course test. Higher clinical knowledge assessment total score and VER scores were seen in the post-test compared to the pre-test (77.8 ± 14.9 vs 59.6 ± 23.1 P < .001) and (77.3 ± 26.6 vs 62.5 ± 32.5, P < .05) respectively. VER perceptions in the course were positive across participants and sustained after deployment.ConclusionsImplementing an educational VER in a national pulmonary and critical care fellows’ virtual course may promote knowledge acquisition and could potentially lead to a positive perception among participants. Longitudinal studies in various contexts are required to further elucidate direct causality between gamification and learner centric outcomes.

IntroductionThere is a lack of a standardized curriculum for the appropriate use of noninvasive ventilation (NIV), which is readily accessible. Management of NIV is a core competency for physicians training in pulmonary and critical care medicine (PCCM). We present a blended model of instruction that was highly successful in our pilot program.MethodsThe curriculum targeted eight first-year PCCM fellows to assess knowledge and confidence in key competencies of NIV management. After a baseline assessment, fellows engaged in both hands-on instruction and traditional didactics in NIV. Following, fellows were encouraged to use the e-learning modules for enhanced instruction. The modules were designed to cover all major aspects of NIV management and with unique interactive patient cases for both inpatient and outpatient uses of NIV.ResultsEight first-year PCCM fellows completed the training and responded to the posttest assessment 4 weeks later. The average multiple-choice questions (MCQs) score increased from 13.5 ± 3.2 (54.0%) to 18.4 ± 1.6 (73.6%) and was significant (p = 0.004). A Likert assessment of learner confidence also showed significant improvement across several key competency domains.ConclusionThis curriculum represents a successful and novel approach to NIV education, a critical but challenging core competency in pulmonary medicine for physicians training in PCCM.

Background: Traditional mannequin-based simulation has been previously demonstrated to be a versatile and effective modality for the education of trainees in the pediatric cardiac intensive care unit (CICU). Unfortunately, creating and maintaining high-fidelity mannequin simulations is resource-intensive. Virtual reality (VR) is an emerging alternative to traditional high-fidelity mannequin simulation for medical education. A previous pilot study by these authors delineated the feasibility of VR in the CICU for the diagnosis and management of patients with hemodynamic compromise. This study sought to compare VR to classic mannequin simulations.Methods: This prospective, single-center study was approved by the Institutional Review Board (IRB) of a quaternary pediatric center and conducted from September to December of 2021. Four common CICU patient scenarios were developed for both VR and mannequins, including supraventricular tachycardia (SVT), postoperative hypotension after a Norwood procedure, pulmonary hypertensive crisis, and apnea with bradycardia. The VR logic was created by the authors, and the programming was completed by SimX (Mountain View, California, USA). Pediatric cardiology and advanced cardiac critical care fellows completed the first two simulations using either VR or mannequins and then crossed over to complete the last two simulations on the other modality. Fellows were assessed on their completion of a critical action checklist for each scenario as well as by an eight-question post-simulation knowledge test. The average number of checklist items completed was calculated for both mannequin and VR-based scenarios, stratified by type of simulation and year of fellowship.Results: A total of 14 fellows completed the study. Overall, the average number of checklist items completed and post-test score increased with each postgraduate year. When comparing the overall number of checklist items completed for all of the simulations between mannequin and VR, there was no significant difference in the means (p = 0.463). On average, fellows completed two to three out of five critical actions, and the average post-test score was 87%. Fellow questionnaires reflected an interest in VR, a lack of previous VR experience, and a general feeling that VR was more immersive than mannequin simulation. The most common complaint by participants was mild nausea.Conclusion: Using VR, multiple common CICU scenarios were designed to accurately reflect complex physiologic changes in real-time, creating an immersive and highly realistic simulation environment. Trainees performed no differently with VR simulations as compared to high-fidelity mannequin simulations in the pediatric CICU. Further investigation is required to demonstrate how VR compares to traditional simulation modalities for long-term knowledge retention.

Health disparities persist among marginalized racial, ethnic, and lower socioeconomic status groups, extending to pediatric intensive care units. Complex interactions between structural forces and provider biases influence patients' risk for critical illness, access, timing, and quality of care. An understanding of how these social influencers of health directly impact health outcomes should be necessary components of pediatric critical care medicine (PCCM) fellowship. Currently, no uniform guidelines exist that provide training in diversity, equity, and inclusion (DEI) in PCCM. We therefore sought to describe the current state of DEI education in PCCM fellowship programs from the program director (PD) perspective. A national survey was conducted among Accreditation Council for Graduate Medical Education-accredited PCCM fellowship PDs to evaluate the state of DEI education. The survey, developed collaboratively and iteratively, encompassed program details, DEI teaching modalities, barriers, and PD perspectives. Statistical analysis was performed using descriptive statistics. Of the 76 PDs surveyed, 47 responded (62% response rate). Although 57% of PDs recognized DEI education as a divisional priority, only 34% had a formal DEI curriculum. Barriers to DEI education included lack of trained faculty, attending time, and engagement. Notably, PDs expressed concerns about faculty competence in delivering DEI education and the scarcity of underrepresented in medicine physicians across trainees and faculty. The findings reveal significant gaps in DEI education within PCCM fellowship programs. Despite recognition of DEI importance, formalized curricula are lacking. The study underscores the necessity for tailored educational interventions and strategies to optimize care.

Point-of-care ultrasound (POCUS) has become a central component in the assessment and management of critically ill patients. Despite its widespread application, there is no standardized curriculum across critical care fellowships. Previous studies have examined the efficacy of ultrasound curricula in enhancing provider comfort and expertise with POCUS. However, these educational interventions are typically limited to specific critical care subspecialties and do not evaluate the longitudinal impact of POCUS training.In this study, we assessed the impact of a longitudinal pulmonary ultrasound curriculum on a multidisciplinary group of critical care fellows. Participants trained in internal medicine, emergency medicine, anesthesia, and neurology first completed a pre-training knowledge assessment. They then attended two one-hour didactic lectures on lung ultrasound (LUS). Hands-on training sessions were provided, with each fellow receiving two-hour scanning sessions under the guidance of critical care ultrasound faculty.Confidence among critical care fellows in acquiring and interpreting images increased from 57% (n = 21) to 79% (n = 19). Similar increases in fellow confidence were noted in using LUS to identify the etiology of respiratory distress and using ultrasound for the diagnostic and therapeutic management of pleural effusions. All study participants were able to accurately complete a comprehensive LUS exam within 10 minutes after training. Quality improvement initiatives and scan reviews provided ongoing feedback over the next year. Upon follow-up with graduates within a year of completing their fellowship, pulmonary ultrasound was routinely used in their practice, with an average frequency of two to three times per week. All respondents reported that pulmonary ultrasound training during fellowship had meaningfully changed how they integrate the tool into their clinical practice.

Background: Pediatric critical care medicine (PCCM) fellowship structures vary widely among programs and have not been examined since 2006. The development of scholarly knowledge and skills is an important part of fellowship training. However, the optimal PCCM fellowship structure to enable fellows' scholarly productivity is unknown. Objective: We examined PCCM fellowship time structure and resources to better understand their association with scholarly productivity. Methods: This is a secondary analysis of cross-sectional survey data from PCCM fellowship program directors. We defined highly productive programs as those in which greater than 75% of fellows published papers from their scholarly projects in the previous 5 years. Analyses investigated the association of scholarly productivity with dedicated scholarship time and program resources and barriers. Results: Forty-nine of 65 PCCM fellowships (75%) completed the survey. Only 20% of fellowships reported that greater than 75% of fellows published papers from their scholarly projects. Median total scholarly activity time was 16 months (interquartile range, 10-18 mo). The total amount of time devoted to scholarly activity was not associated with highly productive programs. Among resources and barriers, only T32 training grants were associated with highly productive programs. Conclusion: We found no relationship between time allocated to scholarly activity and high scholarly productivity in PCCM fellowships. Hence, programs that wish to increase fellows' scholarly productivity should not rely solely on providing more time for scholarly activity. Aside from T32 training grants, no specific resource or barrier that we evaluated is related to productivity.

Critical Care Fellows’ Training Experiences with Obstetric Critical Care: A Cross-Sectional Survey

ABSTRACT Simulation training aims to increase exposure to high-stakes low-frequency events like cardiac arrest. However, within our laboratory-based simulation program, we have observed limited buy-in from internal medicine (IM) residents due to competing patient care obligations and a limited fidelity environment. Mirroring patient data within in situ simulation may provide relevance to ongoing resident patient care obligations, increasing buy-in and confidence in management. Clinical data from presently admitted patients in our institution’s medical intensive care unit (MICU) was ‘mirrored’ to create cardiac arrest simulations. Simulations took place in a vacant MICU patient room with resuscitation equipment, including a code cart, saline-substituted medications, and a mannequin capable of endotracheal intubation. The trainee team consisted of one post-graduate year (PGY) 3 IM resident, two PGY-1 residents, and a critical care fellow. A pre- and post-survey was administered to the PGY-3 IM resident to assess confidence in performing technical and non-technical skills. An advanced cardiac life support (ACLS) instructor evaluated PGY-3 IM resident performance using a skills checklist. Eighty-three percent of PGY 3 residents endorsed changes to their practice following the simulation. Confidence increased in skills related to flexible decision-making skills but not for fixed skills such as following ACLS protocol. Qualitative feedback highlighted realism, spontaneity, and debriefing sessions as the most valuable aspects of the program. In situ mirror simulation may be a useful adjunct for IM residency programs suffering similar concerns with learner motivation during laboratory simulation.

Improving Critical Care Communication with the Serious Illness Conversation Guide at an Academic Medical Center.

The Importance of a Transport Medicine Rotation for a Pediatric Critical Care Fellowship.

A National Assessment of Pediatric Surgical Critical Care Fellowship Structure: Defining the Training Experience.

Extracorporeal cardiopulmonary resuscitation (eCPR) has demonstrated patient outcome-driven benefits for those with out-of-hospital cardiac arrest in refractory ventricular fibrillation/pulseless ventricular tachycardia but remains an infrequent procedure requiring hands-on training. We created a high-fidelity simulation utilizing a cannulation manikin to simulate cardiac arrest in a 57-year-old patient in ventricular fibrillation refractory to standard resuscitation. Participants (consisting of emergency medicine and critical care resident and attending physicians, critical care fellows, advanced practice providers, nurses, pharmacists, and respiratory therapists) were instructed to respond to the simulation by recognizing the indication for eCPR and performing ultrasound-guided percutaneous extracorporeal membrane oxygenation (ECMO) cannulation to facilitate patient transfer to the cardiac catheterization lab. Participants rated their comfort level with various aspects of eCPR on a 5-point Likert scale, both presimulation (N = 27) and postsimulation (n = 17). A total of 27 participants with varied levels of training completed the simulation, with positive feedback from all respondents on the postsimulation survey. A statistically significant increase in comfort scores from pre- to postsimulation was observed across all domains, including knowledge of eCPR candidacy (p < .001), cannulation procedures (p < .001), and overall process (p = .001). Simulation is a valuable tool for ensuring procedural competency, especially for rarely performed and high-risk procedures such as ECMO cannulation. As eCPR becomes more prevalent, it is vital that simulation models be available and practiced on a multidisciplinary level to ensure general knowledge of the indications, procedures, and overall process of eCPR.

Current Approaches to Gastroesophageal Balloon Tamponade Education in Critical Care Fellowships: Findings From a National Survey

Navigating the Difficult Airway: A Multispecialty Training for Pulmonary and Critical Care Fellows

Persistence and Completion Rate of a Year-long Mechanical Ventilation Preceptorial Education Course Among Critical Care Fellows and Attending Intensivists (PIPE Study)

Association of Interventional Pulmonology Fellowship Exposure on Procedural Training for Pulmonary and Critical Care Fellows and Post-graduate Procedural Practice

An Airway Curriculum in Adult Pulmonary and Critical Care Fellowship Program: Fellows' Satisfaction Over Four Years

Pulmonary and Critical Care Fellowship Experiences in Pulmonary Hypertension Education