Critical Care Medicine Training Research Articles

Impact of critical care medicine training programs' palliative care education and bedside tools on ICU use at the end of life.

Intensive care unit (ICU) use at the end of life is rising. Little research has focused on associations among critical care fellows' training, institutional support, and bedside tools with ICU use at the end of life. We evaluated whether hospital and critical care medicine program interventions were associated with ICU use in the last 6months of life for patients with chronic illness. Our observational, retrospective study explored associations between results from a survey of critical care program directors and hospital-level Medicare data on ICU use in the last 6months of life. Program directors evaluated quality of palliative care education in their critical care fellowships and reported on the number of bedside tools and the presence or absence of an inpatient palliative care consultation service. For the 89 hospitals and 71 affiliated training programs analyzed, there were statistically significant relationships between 2 of the explanatory variables-the quality of palliative care education and the number of bedside tools-in ICU use. Each level of increased educational quality (1-5 Likert scale) was associated with a 0.57-day decrease in ICU days, whereas, for each additional, evidence-based bedside tool, there was a 0.31-day decrease. The presence of an inpatient palliative care program was not a significant predictor of ICU use. We found that the quality of palliative care training in critical care medicine programs and the use of bedside tools were independently associated with reduced ICU use at the end of life.

Establishing Pulmonary and Critical Care Medicine as a Subspecialty in China: Joint Statement of the Chinese Thoracic Society and the American College of Chest Physicians

This commentary heralds the recognition in China of a new subspecialty, Pulmonary and Critical Care Medicine, and the first national fellowship training pathway in any medical specialty. Because of striking environmental health-care similarities that existed in the United States, the Chinese medical community decided to model the specialty after that in the United States. Because of its expertise in educating pulmonary and critical care physicians in the United States, the American College of Chest Physicians was chosen by the Chinese Thoracic Society, with the approval of the Chinese government, to help with the transformation of this new specialty. A work group representing the two societies is collaborating to reorganize ICUs within a select group of large teaching hospitals in China and to introduce standardized and rigorous training in pulmonary and critical care medicine as a national program.

Medical Error. The Personal Cost

On a beautiful summer day the July after I finished my fellowship, I prepared for an inaugural ride on a new bike. The bike was a gift to myself to celebrate the end of my formal training in pulmonary and critical care medicine. The sky was clear, a deep “Carolina” blue. There was no wind to warn of a change in weather, no premonition of just how ugly this beautiful day might become. Then, a seemingly insignificant event: a slight irritation on my left toe and a tiny honeybee stuck to my sock. I had no allergy to bees. My breathing was fine. But as the erythema crept up my foot and past my ankle, I grudgingly drove to the emergency department. I parked my car in the deck across the street and started to walk. The entrance to the emergency department felt like it was miles away. I vomited profusely, and sweat dripped down my brow. Despite my “training,” I had underestimated the situation. At triage, I was tachycardic and febrile. I was ushered to a hallway bed (whichmeant I was too sick for the waiting room, but not sick enough for a resuscitation bay). A corticosteroid and an antihistamine were administered intravenously. A repeat pulse oximetry measurement demonstrated that my oxygen saturation had dropped. As I was moved to the resuscitation bay, I remembered the patients I had met there: patients on ventilators, patients with tubes in their noses, their throats, their bladders, and/or their chest. The seriousness of the situation settled into me. In a trauma room, in the ED, at a teaching hospital, in July. My very busy nurse registered me to the new room, moved me to a new bed, hooked me up to telemetry, called for a respiratory therapist, and left to get epinephrine for subcutaneous injection. When she returned with the drug, I noticed that the syringe contained a very small volume. It looked like concentrated epinephrine for an intramuscular injection, but she hooked up the syringe to my IV. I considered asking her about the route of administration, but I said nothing. I had not made good decisions or good assessments aboutmy condition so far that day. A sense of impending doom overwhelmed me. I attributed this to a “fight or flight” response from the epinephrine. I looked for reassurance to the heart monitor, expecting sinus tachycardia. I saw a wide complex tachycardia. I called out for help. The attending physician arrived quickly, shouting to the nurse to administer epinephrine subcutaneously, as he had already ordered. “I received the epinephrine intravenously,” I shouted. “Intravenously”? he questioned. The nurse turned quickly. She glared at me intently, and stated, “I gave it intramuscularly.” Before we resolved that issue, I was intubated. During rounds two days later, the attending physician shared her plan to liberate me from mechanical ventilation. The ache in my chest suggested that extubation would fail. I have a chronic neuromuscular disease that predisposes me to respiratory failure. From previous experience, I had learned to be aware of the pain that was building in my chest. I communicated my concern using the writing tablet provided by the nurse, but was overruled by the team. I was extubated. Within a few hours, I struggled again to breathe. I sat upright and leaned forward into a tripod position in an attempt to catch my breath. The nurse replaced the sweatdrenched bed sheets. The emergency airway team was summoned to reintubate me. When they arrived, the medicine team communicated that I should not receive succinylcholine because of my underlying condition. Rocuronium and etomidate were ordered. Unfortunately, it seemed that the anesthesiologist did not remind the medicine house staff about the different half-lives of these two drugs, drugs that these physicians had probably never ordered or used. I awakened some time later, paralyzed. The endotracheal tube scraped the back of my throat, but I could not cough. I felt restraints around my wrists. Cognitively, I knew why I could not move. As if fierce motivation could overcome neuromuscular blockade, I tried to move anyway. First, my toes and then my eyebrows. To no avail. Next, I tried to communicate distress by thinking of something scary to raise my heart beat (which usually runs in the 50s). When I was finally able to open my eyes, I saw that my curtain was pulled closed. My nurse was gone, probably to lunch after a long morning. My bed was flat—leftover from reintubation. I was

Focused Transthoracic Echocardiography During Critical Care Medicine Training

We designed and implemented a focused transthoracic echocardiography curriculum for critical care medicine fellows participating in 1- and 2-year training programs. We quantitatively evaluated their proficiency in focused transthoracic echocardiography. Prospective study evaluating curriculum implementation and objective assessment of focused transthoracic echocardiography proficiency. Medical and surgical ICUs at an academic teaching hospital. Simulation laboratory. Eighteen critical care medicine fellows. Training in focused transthoracic echocardiography followed by proficiency testing. We assessed the ability of critical care medicine fellows to obtain and interpret focused transthoracic echocardiography images from critically ill patients and a from transthoracic echocardiography simulator. Using a cognitive examination test, we also evaluated each fellow's knowledge with regard to focused transthoracic echocardiography and each fellow's ability to interpret prerecorded focused transthoracic echocardiography images. After training, critical care medicine fellows were able to rapidly obtain five essential focused transthoracic echocardiography views: parasternal long axis, parasternal short axis, apical four chamber, subcostal four chamber, and subcostal inferior vena cava. Fellows were also able to expeditiously identify four important abnormalities: asystole, left ventricular dysfunction, right ventricular dilation and dysfunction, and a large pericardial effusion. A focused transthoracic echocardiography curriculum that includes quantitative measures of proficiency can be integrated into critical care medicine fellowship training programs.

Critical care medicine in Nepal: where are we?

Although critical care medicine has been established as a separate specialty in the rest of the world it is still in its initial stages of development in Nepal and intensive care units (ICUs) here are still in primitive stages. This article describes the history, the types and current status of ICUs, the challenges, and academic training and certification in critical care medicine in Nepal, compared with existing ICUs in other parts of the world.

Are Pediatric Critical Care Medicine Fellowships Teaching and Evaluating Communication and Professionalism?*

To describe the teaching and evaluation modalities used by pediatric critical care medicine training programs in the areas of professionalism and communication. Cross-sectional national survey. Pediatric critical care medicine fellowship programs. Pediatric critical care medicine program directors. None. Survey response rate was 67% of program directors in the United States, representing educators for 73% of current pediatric critical care medicine fellows. Respondents had a median of 4 years experience, with a median of seven fellows and 12 teaching faculty in their program. Faculty role modeling or direct observation with feedback were the most common modalities used to teach communication. However, six of the eight (75%) required elements of communication evaluated were not specifically taught by all programs. Faculty role modeling was the most commonly used technique to teach professionalism in 44% of the content areas evaluated, and didactics was the technique used in 44% of other professionalism content areas. Thirteen of the 16 required elements of professionalism (81%) were not taught by all programs. Evaluations by members of the healthcare team were used for assessment for both competencies. The use of a specific teaching technique was not related to program size, program director experience, or training in medical education. A wide range of techniques are currently used within pediatric critical care medicine to teach communication and professionalism, but there are a number of required elements that are not specifically taught by fellowship programs. These areas of deficiency represent opportunities for future investigation and improved education in the important competencies of communication and professionalism.

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Introduction: Emergency Medicine (EM) trainees have been pursuing critical care medicine (CCM) training for numerous years. During her 2011 national conference remarks, former president of SCCM, Dr. Lipsett, specifically addressed the need to provide EM physicians fellowship “training equivalent to that of our internal medicine, anesthesiology, and surgery colleagues”. There has been an increased interest in formalizing approved CCM fellowship training for EM graduates (grads) within existing ACGME Anesthesiology Critical Care Medicine (ACCM) Fellowship Programs (FP). Hypothesis: EM grads are trained in the triage/resuscitation of undifferentiated critically ill pts and frequently manage multiple sick pts simultaneously. They also, by virtue of their training, are competent in a wide variety of CCM procedural skills (airway techniques, central venous access, bedside ultrasound, cardioversion, etc). We propose that existing ACCM programs could incorporate EM grads for formal training and certification. Methods: Currently, 51 ACCM FP exist in the United States. A survey was circulated amongst the ACCM program directors (PD) to assess attitudes and perceptions regarding the training of EM grads. We also requested information regarding ACCM FP that have previously or are currently training EM grads. Results: 46/51 (90%) ACCM FP replied. 20 (43%) programs are currently or have trained EM grads. 38 of 46 respondents (83%) either “strongly agree” or “agree” that EM trainees have the potential to be good intensivists. 35/46 (76%) “strongly agree” or “agree” that a pathway for training and board eligibility in CCM should be available for EM trainees in ACCM. 56% felt that the training should be 2yrs in length, while 28% felt it should be 1yr. Based on these results, a formal letter (endorsed by SCCM) of recommendation supporting the creation of a specialty track within ACCM FP was submitted to the Anesthesiology Residency Review Committee and the American Board of Anesthesiology. Conclusions: EM trainees are currently being trained in ACCM FP. The majority of ACCM FP would accept a formalized training tract leading to board certification. Further steps need to be taken to delineate a formal curriculum for EM/CCM fellows.

Using standardized family members to teach communication skills and ethical principles to critical care trainees*

We sought to determine the effectiveness of standardized family members for improving communication skills and ethical and legal knowledge of senior intensive care unit trainees. Multimodal evaluation of mixed-methods educational intervention. Postgraduate critical care medicine academic program. Postgraduate subspecialty critical care medicine trainees. Communication workshop featuring a short didactic session and four simulated family meetings using trained professionals as standardized family members. Ethical and legal knowledge and comfort with communication (before and after the workshop) and communication skill (during the workshop). Fifty-one postgraduate critical care medicine subspecialty trainees participated in the workshop over a 5-yr period. Ethical and legal knowledge and comfort scores improved significantly among trainees who participated in the workshop. Ninety percent of trainees felt that the workshop had met or exceeded their expectations and would recommend it to other trainees. Ninety-eight percent of trainees felt that the workshop had met the highest priority learning objectives they identified. Communication scores showed a trend towards improvement over the course of the workshop, although the improvements were not significant. Participants reflecting on the workshop >1 yr later overwhelmingly felt that it had prepared them for real communication challenges in training and practice. This workshop was effective for improving ethical and legal knowledge and comfort with communication among critical care medicine trainees. Participants overwhelmingly felt that it had met their learning needs and that it was an effective teaching tool that had prepared them for real communication challenges in training and practice. It could be used in a variety of contexts to address an often-neglected area of education.

Deferred Admission to the Intensive Care Unit: Rationing Critical Care or Expediting Care Transitions?

Deferred Admission to the Intensive Care Unit: Rationing Critical Care or Expediting Care Transitions?

Children's Cardiology Up-to-Date Online Resources for Education (CUORE) Project: Remote Education for Training in Pediatric Critical Care Medicine

Children's Cardiology Up-to-Date Online Resources for Education (CUORE) Project: Remote Education for Training in Pediatric Critical Care Medicine

Intensivists: don't quit your day job...yet!

Management of critically ill patients by physicians with advanced training in critical care medicine has been associated with improved outcomes in a variety of disease states, such as acute lung injury [2] and intracranial hemorrhage [3], as well as following traumatic injury [4] and aortic [5] or esophageal [6] surgery. Additionally, a systematic review revealed that outcomes were better in a cohort of critically-ill patients managed by intensivists in high-intensity ICUs (defi ned as closed ICUs or ICUs with mandated intensivist consultation) as compared to low-intensity ICUs, with an overall reduction in the relative risk (RR) of both hospital and ICU mortality [7]. Furthermore, experts predict that there will be a shortage of critical care physicians in the very near future that is projected to increase dramatically as the population ages Expanded Abstract Citation Levy MM, Rapoport J, Lemeshow S, Chalfi n DB, Phillips G, and Danis M: Association between Critical Care Physician Management and Patient Mortality in the Intensive Care Unit. Ann Intern Med 2008 Jun 3, 148(11): 801-9 [1]. Background Critically ill patients admitted to intensive care units (ICUs) are thought to gain an added survival benefi t from management by critical care physicians, but evidence of this benefi t is scant. Methods Objective: To examine the association between hospital mortality in critically ill patients and management by critical care physicians. Design: Retrospective analysis of a large, prospectively collected database of critically ill patients. Setting: 123 ICUs in 100 U.S. hospitals. Subjects: 101,832 critically ill adults. Intervention: None. Outcomes: Through use of a random-eff ects logistic regression, investigators compared hospital mortality between patients cared for entirely by critical care physicians and patients cared for entirely by non-critical care physicians. An expanded Simplifi ed Acute Physiology Score was used to adjust for severity of illness, and a propensity score was used to adjust for diff erences in the probability of selective referral of patients to critical care physicians. Results Patients who received critical care management (CCM) were generally sicker, received more procedures, and had higher hospital mortality rates than those who did not receive CCM. After adjustment for severity of illness and propensity score, hospital mortality rates were higher for patients who received CCM than for those who did not. The diff erence in adjusted hospital mortality rates was less for patients who were sicker and who were predicted by propensity score to receive CCM. Residual confounders for illness severity and selection biases for CCM might exist that were inadequately assessed or recognized. Conclusion In a large sample of ICU patients in the United States, the odds of hospital mortality were higher for patients managed by critical care physicians than those who were not. Additional studies are needed to further evaluate these results and clarify the mechanisms by which they might occur.

THE AMERICAN BOARD OF ANESTHESIOLOGY

The American Board of Anesthesiology (ABA) will administer examinations for certification in the subspecialties of critical care medicine and pain medicine on Saturday, October 23, 2010, via computer at more than 300 Prometric®, a part of the Thomson Corporation, Testing Centers located throughout the United States, Canada, and the U.S. Territories. The ABA will mail scheduling permits to candidates approximately three months prior to the exam.All applicants for subspecialty certification must satisfactorily complete 12 months of training in an ACGME-accredited critical care medicine or pain medicine program by September 30, 2010. They also must be certified in anesthesiology by the ABA or scheduled for ABA oral examination in 2010. After February 1, 2010, applicants may use the ABA Web site (www.theABA.org) to submit their application for a subspecialty certification examination electronically. The standard application deadline is March 31, 2010. The ABA will consider late applications received by April 15, 2010. Applications received after the late deadline will not be considered. The ABA will make a decision about an applicant's qualifications for subspecialty examination by May 15, 2010.The examination for certification in hospice and palliative medicine is offered biennially. The 2010 examination will take place on November 16, 2010, and will be administered via computer at more than 200 Pearson VUE test centers (please note this exam date is subject to change). The ABA will inform candidates when they may schedule their examination with Pearson VUE.Applicants for subspecialty certification who have satisfactorily completed 12 months of training in an ACGME-accredited hospice and palliative medicine fellowship program may be admitted to the examination via temporary criteria. The temporary criteria include a Training Pathway and a Practice Pathway. For additional information please refer to Section 3 of the ABA Booklet of Information available on the ABA Web site at www.theABA.orgunder the Publications link.Applicants also must be certified in anesthesiology by the ABA or scheduled for ABA oral examination in 2010. After February 1, 2010, applicants may use the ABA Web site (www.theABA.org) to submit their application for a subspecialty certification examination electronically. The standard application deadline is March 31, 2010. The ABA will consider late applications received by April 15, 2010. Applications received after the late deadline will not be considered. The ABA will make a decision about an applicant's qualifications for subspecialty examination by May 15, 2010.

DEVELOPMENT AND VALIDATION OF A ONE-DAY STRUCTURED BRONCHOSCOPY CURRICULUM FOR FIRST YEAR PULMONARY AND CRITICAL CARE MEDICINE TRAINEES IN SOUTHERN CALIFORNIA

PURPOSE: To demonstrate the effectiveness, usability, and educational value of a competency-oriented, one-day structured curriculum designed to improve cognitive knowledge and technical skill in flexible bronchoscopy for first year pulmonary and critical care medicine trainees.

Editorial for the Inaugural Issue

<!--[if !mso]> <style> v\:* {behavior:url(#default#VML);} o\:* {behavior:url(#default#VML);} w\:* {behavior:url(#default#VML);} .shape {behavior:url(#default#VML);} </style> <![endif]--><!--[if gte mso 9]><xml> 12.00 </xml><![endif]--><!--[if gte mso 9]><xml> Normal 0 false false false EN-US X-NONE X-NONE MicrosoftInternetExplorer4 </xml><![endif]--><!--[if gte mso 9]><xml> </xml><![endif]--> <!--[if gte mso 10]> <style> /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-priority:99; mso-style-qformat:yes; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:11.0pt; font-family:"Calibri","sans-serif"; mso-ascii-font-family:Calibri; mso-ascii-theme-font:minor-latin; mso-fareast-font-family:"Times New Roman"; mso-fareast-theme-font:minor-fareast; mso-hansi-font-family:Calibri; mso-hansi-theme-font:minor-latin; mso-bidi-font-family:"Times New Roman"; mso-bidi-theme-font:minor-bidi;} </style> <![endif]--><!--[if gte mso 9]><xml> </xml><![endif]--><!--[if gte mso 9]><xml> </xml><![endif]--> <!--[if gte vml 1]> <![endif]-->It is with pleasure that we launch the inaugural issue of the Sri Lanka Journal of Critical Care. This is an official publication of the Postgraduate Institute of Medicine, University of Colombo, Sri Lanka. The journal is peer-reviewed, and is Sri Lanka's first online-only open access journal. We do not charge a subscription fee, nor do we charge authors. The open-access model is now a favoured model for publication of scientific research, and enables wider dissemination of scientific publications. Making the journal an online only publication greatly reduces the cost of publication, while making it possible to provide it through an open-access model. The journal aims to foster research and education in critical care medicine in Sri Lanka. We are indexed on Google Scholar. Critical Care Medicine is gradually being established as a subspecialty in Sri Lanka. The Specialty Board in Critical Care and Emergency Medicine was established by the Postgraduate Institute of Medicine to function under the Board of Study for Multidisciplinary Study Courses recently. As its first activity, a Postgraduate Diploma in Critical Care was commenced this year, and the first batch of trainees have commenced training. The aim of this diploma programme is to enhance the training of junior doctors working in intensive care units throughout the country. Critical care medicine is essentially a multidisciplinary specialty. In keeping with many models of critical care medicine in Europe, the United States, and other developed countries, we support the view that training in critical care medicine must allow entry from many different disciplines, such as clinical medicine, anaesthesiology, surgery, paediatrics, obstetrics and gynaecology, and many others. We sincerely hope this journal would provide a platform for the dissemination of research, scientific thought and debate in the field of critical care medicine in Sri Lanka. We particular encourage local researchers to submit their work to our journal. We are grateful for the support given towards us towards the establishment of this journal by the Director, PGIM, the staff at the Medical Education Resource Centre of the PGIM, and members of the Specialty Board in Critical Care, and the Editorial Board. We also thank the INASP (International Network for the Availability of Scientific Publications) which supports us to make our journal available online through their Sri Lanka Journals Online project (<a href="/">www.sljol.info</a>). In particular, we thank Mrs Sioux Cumming, Programme Officer, Publishing Support, INASP, for her continuing support and assistance in maintaining the journal. DOI: 10.4038/sljcc.v1i1.936

Pediatric Specialized Transport Teams Are Associated With Improved Outcomes

The goal was to test the hypothesis that interfacility transport performed by a pediatric critical care specialized team, compared with nonspecialized teams, would be associated with improved survival rates and fewer unplanned events during the transport process. A single-center, prospective, cohort study was performed between January 2001 and September 2002. A total of 1085 infants and children at referral community hospitals with requests for retrieval by the Children's Hospital of Pittsburgh transport team were studied; 1021(94%) were transported by a specialty team and 64 (6%) by nonspecialized teams. Unplanned events during the transport process and 28-day mortality rates were assessed. Unplanned events occurred for 55 patients (5%) and were more common among patients transported by nonspecialized teams (61% vs 1.5%). Airway-related events were most common, followed by cardiopulmonary arrest, sustained hypotension, and loss of crucial intravenous access. After adjustment for illness severity, only the use of a nonspecialized team was independently associated with an unplanned event, and death was more common among patients transported by nonspecialized teams (23% vs 9%). Transport of critically ill children to a pediatric tertiary care center can be conducted more safely with a pediatric critical care specialized team than with teams lacking specific training and expertise in pediatric critical care and pediatric transport medicine.

Learning in patient-based education sessions: A prospective evaluation*

The educational impact of on-call scheduling for physicians in training is not well understood. The benefit of patient-based educational sessions during postcall periods may be enhanced by the greater patient familiarity associated with long on-call shifts, or it may be attenuated by fatigue. The objective was to evaluate the impact of in-house call on cognitive attention, learning, and recall of critical care medicine trainees, before and after a reduction in call period. A prospective before and after survey during 8 wks in 2004. Two critical care units at the Hospital for Sick Children, Toronto. Trainees in a university-affiliated critical care medicine program at the Hospital for Sick Children. Duty hour reduction from 26.5-hr to 18-hr on-call shifts. Likert scales were completed after morning educational seminars self-reporting alertness, concentration, how well discussions were followed, and the acquisition of new or practice changing knowledge. Respondents were classified according to how recently they had been on call. Eleven trainees completed 231 questionnaires (80% response rate). Fellows with more recent on-call periods had reduced concentration (p = .002), alertness (p < .0001), and recall of the previous session (p = .009) and followed discussions less well (p = .019). Eighteen-hour shifts were associated with increased postcall alertness (p = .002), concentration (p = .03), and assimilation of discussions (p = .045). However, neither the duration of call nor the length of time since being on call was associated with differences in the acquisition of new theoretical or practice-changing knowledge. Reduced mental attention after being on call is more pronounced after longer shifts. Learning was not affected by shift duration or by how recently trainees were on call. Increased patient familiarity does not augment learning in patient-based medical education.

Sleep Medicine Fellowships—Accomplishments and More Issues

This year marks a relatively obscure event for most of us. It is the end of the initial accreditation cycle for those Sleep Medicine programs who were the vanguard of the ∼20 institutions that were the first to receive approval by the Accreditation Council for Graduate Medical Education (ACGME) for Sleep Medicine training. Obviously, for these institutions, it means considerable time spent by the program director and faculty in the preparation of the “PIF” (Program Information Form) and “dreaded” anticipation of the inevitable site visit. However, for the rest of us who fortunately will not have to complete a PIF, it is a marker of the gradual maturation of Sleep Medicine as a specialty of medicine. ACGME accreditation of our training programs means acceptance by the medical community that we have both a distinct base of scientific knowledge and a focused area of medical practice. The accreditation process also became the impetus for the development of an American Board of Medical Specialties (ABMS) certification examination in Sleep Medicine with the first examination to be given next month. These events are a result of hard work by colleagues who are too numerous to be recognized in this abbreviated message. Several years ago, I was fortunate to serve you as a member of the AASM (American Academy of Sleep Medicine) Board of Directors and was a participant in a discussion of what to include in our strategic plan. At that time, there were slightly over 25 AASM accredited fellowships, and there was considerable debate concerning whether a goal of 50 fellowship programs was achievable. Some of us, myself included, thought that this was unlikely to occur. Fortunately, I am not making my living as a psychic, and I am happy to report that I was quite wrong. At the current time, there are 57 ACGME accredited fellowship programs with 142 training positions1. However, our field's success in developing training programs raises an additional important issue. How many Sleep Medicine clinicians does this country require? If we conservatively count only those individuals who become ABMS certified and those who will be eligible for certification, there will be 142 people entering the field each year plus those who will become certified by taking the examination through practice/American Board of Sleep Medicine eligibility (over 1900 will be taking the first exam). Will this be sufficient to sustain our field? Do we need to encourage the development of more training programs? In comparison, there are 183 adult Pulmonary and/or Critical Care Medicine training programs with ∼550 first year positions and 91 Clinical Neurophysiology training programs with 282 positions in one year programs similar to Sleep Medicine training1. At a time when there is a debate in our field as to the role of the Sleep Medicine clinician in the delivery of patient care, these are critical questions, and ones that should be addressed in the near future. Another issue related to fellowship training is the content and length of training. In the next year, there will be a scheduled revision of the training requirements for Sleep Medicine. The Sleep Medicine community will be asked for input regarding the relevance of the current requirements for the practice of Sleep Medicine now and over the next several years. Should there be additions or deletions to the requirements? Is a one year training program appropriate? Should training be at least two years, similar that required by virtually all the Internal Medicine and Pediatric subspecialties? This latter question has significant cost and person power implications, but may be important in development of academic sleep clinicians. This two year anniversary of initial accreditation of Sleep Medicine training programs may not directly affect most of us. Nonetheless, it serves as a reminder that important issues related to person power and the practice of Sleep Medicine remain unresolved and should be addressed in the near future.

AIRWAY MANAGEMENT OUTSIDE OF THE OPERATING ROOM: A SURVEY OF CRITICAL CARE MEDICINE PROGRAM DIRECTORS

PURPOSE: Airway management is a crucial skill important in prevention of hypoxic cerebral injury. The management of the airway outside of the operating room (OR) is often carried out by diverse personnel and under difficult conditions. The best method for teaching and maintaining these skills is not clear. Our purpose was to survey adult Critical Care Medicine training programs in the United States regarding airway management outside of the OR.

Pediatric workforce: A look at pediatric critical care medicine data from the American Board of Pediatrics

his report, which is part of a series discussing workforce trends for general pediatrics and related subspecialty areas, highlights the American Board of Pediatrics’ (ABP) workforce data for pediatric critical care medicine. Readers are encouraged to read the initial report in the series, because it provides information about general pediatrics and summary nformation about other ABP subspecialties. In 1987, pediatric critical care medicine became the seventh ABP subboard to offer certification examination, with the first examination yielding 182 board-certified pediatric critical care physicians. Today, lmost 1300 pediatricians have been certified by the ABP as pediatric critical care physicians. This report provides a snapshot f the current ABP workforce data for this subspecialty. The full ABP workforce data are available on the ABP Web site at ww.abp.org.

A curriculum in critical care medicine for maternal-fetal medicine fellows

Critical care education in maternal-fetal medicine has typically been limited or has been driven entirely by clinical cases. A pilot program was created to systematize critical care training within the context of an existing maternal-fetal medicine fellowship. The program included a lecture series, a Web-based learning module, specific scenarios played out in a human simulator lab, and a clinical intensive care unit rotation. Fellows' knowledge was assessed by pre- and posttest. Objective knowledge was demonstrated to increase after 1 yr of training. Fellows' impression of the curriculum was positive. More structured critical care medicine training is feasible within a maternal-fetal medicine fellowship. A multimodal curriculum to teach critical care within a maternal-fetal medicine fellowship appears promising and could be implemented elsewhere. Interest in this area should be cultivated.