Rotation Objectives

Clinical Knowledge and Experience

• Understand the effects of anesthesia on pulmonary and cardiac function.
• Recognize indications, contraindications, side effects, and safe application of muscle relaxants, narcotics, anxiolytics, and anesthetic agents.
• Demonstrate techniques for establishing and maintaining an open airway.
• Maintain normal cardiac physiology in patients with surgical pathology or while under sedation or general anesthesia.
• Recognize and appropriately treat hemodynamic instability using intravenous pressors and antihypertensives.
• Apply ventilatory support, liberation, and respiratory care techniques.
• Develop competence in intravenous and arterial access techniques.

Procedural Skills

• Manage the airway in non-intubated, unconscious, or paralyzed patients.
• Perform procedures related to intravenous access, arterial line placement, and hemodynamic monitoring.
• Use reservoir masks and other adjuncts for supplemental oxygen delivery.

Diagnostic Studies and Hemodynamic Data Interpretation

• Acquire knowledge and clinical experience in interpreting diagnostic data relevant to anesthesia and perioperative hemodynamic monitoring.

Core Competencies

• Patient Care: Provide safe and effective perioperative management.
• Medical Knowledge: Understand pharmacology, physiology, and pathophysiology relevant to anesthesiology.
• Practice-Based Learning and Improvement: Participate in multidisciplinary conferences and apply evidence-based approaches to patient care.
• Interpersonal and Communication Skills: Communicate effectively with surgical teams, anesthesia staff, and other services.
• Professionalism: Demonstrate ethical behavior, obtain informed consent, and maintain patient privacy.
• Systems-Based Practice: Understand hospital systems and collaborate for optimal patient care.

Evaluation

A written evaluation will be provided by Scripps Green faculty at the end of the rotation, assessing cognitive, patient management, procedural, and humanistic skills. Feedback will be reviewed with the fellow and then shared with the NMCSD Fellowship Director for inclusion in the permanent file.

Educational Purpose and Description

While “elective” implies choice, there are strongly encouraged electives (e.g., rotations at affiliated training sites such as Scripps Interventional Pulmonology, Scripps Sleep Medicine, UCSD Interventional Pulmonology, VA Consult Service, UCSD Lung Transplant) that are offered based on availability and program year. Fellows should discuss preferences with the Program Director; unselected elective blocks may be assigned to ensure comprehensive training or address specific competency needs.

Past fellows have pursued advanced procedural skills, additional Critical Care experience in various subspecialty ICUs, dedicated research endeavors, and unique military operational medicine rotations (e.g., aboard the USNS Mercy for humanitarian missions, extended surgical critical care, or specialized training in Interstitial Lung Diseases at national referral centers). Fellows may concentrate their elective time in a single area or divide it among several, depending on career goals.

Requirements for Electives

• Fellows must generally maintain their NMCSD continuity clinic responsibilities (typically one half-day per week) unless on an out-of-area rotation where this is not feasible.
• Fellows must prepare competency-based goals and objectives for each elective rotation, mirroring the format used for core rotations in this handbook. These must be approved by the Program Director in advance.
• Each elective requires a designated faculty mentor/supervisor at the elective site.
• A clear evaluation plan must be in place to assess the fellow’s performance and the educational value of the rotation. Evaluations will be completed by the elective rotation supervisor and submitted to the NMCSD Program Director.

Rotation Objectives

Clinical Knowledge and Experience

• Pathophysiology, diagnosis, and management of acute lung injuries (e.g., ARDS, radiation, inhalation, trauma).
• Management of respiratory failure from various etiologies (including ARDS, neuromuscular disorders, obstructive lung disease).
• Diagnosis and management of critical illness related to cardiovascular, renal, gastrointestinal, neurologic, endocrine, hematologic, musculoskeletal, immunologic, and infectious diseases.
• Management of electrolyte and acid-base disorders, including endocrinologic and nutritional considerations in critically ill patients.
• Diagnosis and management of hematologic and coagulation disorders in the ICU setting.
• Management of anaphylaxis and acute allergic reactions.
• Principles of trauma and surgical critical care relevant to medical intensivists.
• Understanding of pharmacokinetics, pharmacodynamics, and drug metabolism in critical illness.
• Management of cardiac and cardiothoracic surgical disorders requiring critical care.
• Application of process improvement, continuous quality assurance, and bundled care strategies for infection prevention (e.g., VAP, CLABSI).

Procedural Skills

(Indications, contraindications, complications, limitations, and proficient performance under appropriate supervision)

• Airway establishment and maintenance in non-intubated, unconscious, or paralyzed patients (including direct and video laryngoscopy, bronchoscopic intubation).
• Operation of various mechanical ventilation modes (pressure-, volume-, time-, flow-cycled) and non-invasive ventilation.
• Use of various oxygen delivery systems (reservoir masks, CPAP, high-flow nasal cannula).
• liberation from mechanical ventilation and application of respiratory care techniques.
• Management of pneumothorax (needle decompression, chest tube insertion and drainage systems).
• Arterial puncture and blood sampling.
• Insertion and management of central venous, arterial, and pulmonary artery catheters.
• Basic and advanced cardiopulmonary resuscitation (ACLS protocols).
• Emergency cardioversion and defibrillation.
• Diagnostic and therapeutic procedures (e.g., thoracentesis, paracentesis, lumbar puncture as indicated).
• Hemodynamic monitoring (interpretation, calibration, and operation of recording systems, including POCUS).
• Administration of parenteral nutrition.
• Assistance with or management of continuous renal replacement therapy (CRRT).
• Intracranial pressure monitoring awareness.

Interpretation of Diagnostic Studies

• Interpretation of chest radiographs, CT scans, and ultrasound in the ICU (e.g., RUSH exam, E-FAST, pleural and abdominal examinations, cardiac POCUS).
• Interpretation of cardiac output measurements (thermodilution and other techniques).
• Analysis of arterial and venous blood gases, electrolyte levels, antibiotic levels, and sensitivities.
• Assessment of metabolism and nutrition in critically ill patients.
• Interpretation of coagulation studies and management of massive transfusions and hemostatic defects.
• Calculation of oxygen content, intrapulmonary shunt, and alveolar-arterial gradients.
• Application of pharmacokinetic principles in dosing medications.

Core Competencies / Competency-Based Goals by Year

Evaluation

A written evaluation assessing cognitive, patient management, procedural skills, ACGME competencies (including professionalism and communication), and 360-degree feedback will be provided at the end of the rotation. Areas for improvement are reviewed with the fellow and forwarded to the Program Director and Education Committee for inclusion in the trainee’s permanent file.

Rotation Objectives

Clinical Knowledge and Experience

• Obstructive lung diseases (asthma, bronchitis, emphysema, bronchiectasis, cystic fibrosis)
• Pulmonary malignancy (primary and metastatic), including initial diagnostic workup and staging principles
• Pulmonary infections (including tuberculosis, fungal infections, and infections in immunocompromised hosts)
• Diffuse interstitial lung disease
• Pulmonary vascular diseases (primary/secondary pulmonary hypertension, vasculitis, hemorrhage syndromes)
• Occupational and environmental lung disease
• Drug-induced and iatrogenic respiratory disease
• Acute lung injuries (radiation, inhalation, trauma)
• Pulmonary manifestations of systemic diseases (e.g., collagen vascular disorders)
• Respiratory failure (ARDS, neuromuscular disorders, acute exacerbations of chronic obstructive lung disease)
• Pleural and mediastinal disorders (e.g., effusions, pneumothorax, masses)
• Genetic and developmental respiratory disorders
• Evaluation of postoperative pulmonary complications and pulmonary problems related to pregnancy

Procedural Skills

(Indications, contraindications, complications, limitations, and proficient performance under appropriate supervision)

• Management of pneumothorax (needle decompression, chest tube insertion and drainage systems)
• Interpretation and supervision of pulmonary function testing (spirometry, flow-volume studies, lung volumes, diffusing capacity, ABG analysis, exercise studies)
• Diagnostic and therapeutic procedures such as thoracentesis, pleural biopsy (if applicable), and flexible bronchoscopy (including BAL, brushings, endobronchial and transbronchial biopsies)
• Examination and interpretation of sputum, bronchopulmonary secretions, pleural fluid, and lung tissue samples (for infectious agents, cytology, histopathology)

Interpretation of Diagnostic Studies

• Chest radiographs (portable, PA/lateral)
• Computed tomography (CT) scans of the chest (with/without contrast, HRCT, CTA)
• Radionuclide scans (e.g., V/Q scans)
• Pulmonary angiograms (interpretation principles)
• Interpretation of antibiotic levels and sensitivities relevant to pulmonary infections

Core Competencies / Competency-Based Goals by Year

Evaluation

A written evaluation will be completed at the end of this rotation by the supervising attending(s), assessing cognitive ability, patient management, procedural skills (if applicable), and professional conduct, based on ACGME competencies. Feedback will be discussed with the fellow before being forwarded to the Program Director for inclusion in the permanent file.

Rotation Objectives

Clinical Knowledge and Experience

• Pathophysiology of traumatic injury and principles of managing critically injured trauma patients (e.g., TBI, spinal cord injury, thoracic/abdominal trauma).
• Management of end-stage organ dysfunction in the context of trauma and critical illness.
• Diagnosis and management of ARDS in trauma patients.
• Principles of critical care transport, including air transport considerations.
• Advanced airway management techniques for non-intubated and difficult airway patients.
• Application of noninvasive and invasive mechanical ventilation strategies, including protocols for optimal ventilation, oxygenation, and liberation in trauma populations.
• Management of traumatic and spontaneous pneumothorax.
• Diagnosis and management of various forms of shock using noninvasive, invasive, and POCUS-based hemodynamic data.
• Understanding of respiratory mechanics, gas exchange, and control of breathing in critically ill trauma patients.
• Principles of critical care ultrasonography for resuscitation and ongoing management.
• Examination and interpretation of diagnostic specimens relevant to trauma and critical care.
• Interpretation of imaging studies (chest radiography, CT scans, pulmonary angiograms, radionuclide scans, and others) in trauma settings.

Procedural Skills

(Indications, contraindications, complications, limitations, and proficient performance under appropriate supervision)

• Direct and video laryngoscopic intubation.
• Central venous catheter insertion (including large-bore resuscitation and dialysis catheters).
• Arterial line insertion.
• Tube thoracostomy for pneumothorax and hemothorax.
• Bronchoscopy (including diagnostic BAL and bronchoscopic intubation).
• Ventilator management (invasive and non-invasive).
• Paracentesis, pericardiocentesis (if indicated), and thoracentesis.
• Intracranial pressure monitoring principles and interpretation.
• Familiarity with management of continuous renal replacement therapy (CRRT) and other forms of dialysis.
• Critical care ultrasonography (e.g., E-FAST, RUSH exam, basic echo, lung US, DVT screening).
• Calculation and interpretation of oxygen content, oxygen delivery, shunt fraction, and alveolar-arterial gradient.
• Proper utilization, zeroing, and calibration of pressure transducers and hemodynamic monitoring equipment.
• Swan-Ganz catheter insertion and interpretation (if utilized).

Core Competencies

• Patient Care: Providing comprehensive care to critically ill trauma and surgical patients, including management of multi-organ failure and complex physiologic derangements.
• Medical Knowledge: Deepening understanding of trauma pathophysiology, advanced critical care interventions, and evidence-based management strategies for shock, ARDS, and sepsis.
• Practice-Based Learning and Improvement: Participating in trauma M&M conferences, unit-based QI projects, and applying current literature to patient care.
• Interpersonal and Communication Skills: Effectively communicating with trauma surgery teams, consulting services, patients, and families, especially in high-stress situations and during discussions about prognosis and goals of care.
• Professionalism: Demonstrating ethical conduct, resilience, and respect for all members of the multidisciplinary team.
• Systems-Based Practice: Navigating the complexities of a high-volume trauma center, understanding resource allocation, and participating in efficient patient flow and transfer processes.

Evaluation

At the end of the rotation, the fellow will receive a written evaluation from Intermountain faculty assessing cognitive knowledge, patient management skills, procedural competence, and interpersonal attributes based on ACGME competencies. This evaluation, including areas for improvement, will be discussed with the fellow and sent to the NMCSD Fellowship Director for inclusion in the fellow’s permanent file.

Rotation Objectives

Clinical Knowledge and Experience

• Diagnosis and management of multidrug-resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB).
• Diagnosis and management of various nontuberculous mycobacterial (NTM) lung diseases.
• Management of bronchiectasis and its complications, particularly in the context of chronic infection.
• Principles of medical treatment for mycobacterial diseases, including detailed knowledge of first-line and second-line anti-mycobacterial agents, their mechanisms of action, pharmacokinetics, drug interactions, and adverse effect profiles.
• Indications for and interpretation of therapeutic drug monitoring (TDM) for anti-mycobacterial agents.
• Indications for surgical management of severe or localized mycobacterial disease.
• Role of adjunctive therapies, such as airway clearance techniques (e.g., chest physiotherapy, device-assisted clearance) and nutritional support.
• Understanding of underlying conditions predisposing individuals to chronic or refractory mycobacterial infections (e.g., cystic fibrosis, immunodeficiencies, structural lung disease).
• Public health considerations related to mycobacterial diseases, including infection control, contact tracing, and reporting requirements.

Procedural Skills

(Familiarity with indications, contraindications, and interpretation; performance under supervision if opportunities arise)

• Bronchoscopy and other methods for lower respiratory tract sampling (e.g., BAL, biopsies) for diagnosis of mycobacterial infections.
• Techniques for sputum induction and processing.
• Understanding and application of mucociliary clearance techniques.
• Interpretation of radiographic findings characteristic of chronic lung infections, including TB and NTM disease (e.g., cavities, bronchiectasis, nodules).

Core Competencies

• Patient Care: Providing specialized care for patients with complex mycobacterial lung diseases, focusing on long-term management strategies and patient education.
• Medical Knowledge: Acquiring in-depth knowledge of mycobacteriology, pharmacology of anti-mycobacterial drugs, and management of drug resistance and toxicity.
• Practice-Based Learning and Improvement: Applying evidence-based guidelines to patient care, participating in case conferences, and learning from a national referral center’s expertise.
• Interpersonal and Communication Skills: Communicating effectively with a multidisciplinary team, patients (often with chronic illness), and public health officials.
• Professionalism: Maintaining ethical standards in managing challenging cases, including adherence to treatment and infection control measures.
• Systems-Based Practice: Understanding the role of a specialized referral center, coordinating care with local providers, and navigating public health systems related to TB and NTM.

Evaluation

The fellow will receive a written evaluation from National Jewish Health faculty at the end of the rotation, focusing on cognitive knowledge, patient management, procedural ability (if applicable), and interpersonal skills based on ACGME competencies. This will be discussed with the fellow and forwarded to the NMCSD Fellowship Director for inclusion in the fellow’s permanent record.

Rotation Objectives

Clinical Knowledge and Experience

• In-depth understanding of respiratory physiology as it applies to PFTs (e.g., lung mechanics, gas exchange, ventilatory control).
• Familiarity with indications, contraindications, and limitations of various PFTs.
• Ability to interpret patterns of PFT abnormalities (obstructive, restrictive, mixed, gas exchange impairment, neuromuscular weakness).
• Knowledge of reference values, predicted equations, and lower limits of normal (LLN).
• Understanding the role of PFTs in preoperative assessment, disability evaluation, and monitoring disease progression or response to therapy.

Procedural and Technical Skills

(Supervision, performance, and interpretation)

• Spirometry (FVC, FEV1, FEV1/FVC, FEF25-75%, flow-volume loops), including pre- and post-bronchodilator testing.
• Measurement of lung volumes (e.g., by body plethysmography, nitrogen washout, or helium dilution).
• Measurement of diffusing capacity for carbon monoxide (DLCO).
• Arterial blood gas (ABG) sampling and interpretation.
• Bronchoprovocation testing (e.g., methacholine challenge), including safety protocols.
• Cardiopulmonary exercise testing (CPET) setup, conduct, and interpretation.
• Six-minute walk test (6MWT) performance and interpretation.
• Basic PFT equipment calibration and quality control procedures.

Core Competencies

• Patient Care: Supervise and accurately interpret PFTs, ensuring patient safety and comfort during testing. Integrate PFT results into comprehensive patient assessment and management plans.
• Medical Knowledge: Demonstrate robust knowledge of respiratory physiology, pathophysiology, and the technical aspects of PFTs. Stay current with ATS/ERS guidelines for PFT performance and interpretation.
• Practice-Based Learning and Improvement: Critically evaluate PFT quality, identify sources of error, and participate in laboratory quality assurance processes. Use PFT data to inform evidence-based clinical practice.
• Interpersonal and Communication Skills: Clearly explain PFT procedures to patients. Effectively communicate PFT interpretations and their clinical significance to referring providers and other healthcare team members.
• Professionalism: Maintain a professional demeanor, ensure timely interpretation and reporting of PFT results, and adhere to ethical standards.
• Systems-Based Practice: Understand the role of the PFT lab within the healthcare system, including test ordering, scheduling, reporting, and resource utilization. Ensure compliance with laboratory accreditation standards.

Evaluation

A written evaluation will be completed by the PFT Lab Director at the end of the rotation, focusing on cognitive knowledge (interpretation skills), understanding of PFT techniques, quality assessment, professionalism, and communication. This evaluation will be discussed with the fellow and then sent to the Program Director for inclusion in the permanent record.

Rotation Objectives

Clinical Knowledge and Experience

• Comprehensive understanding of normal and variant thoracic anatomy as depicted on various imaging modalities.
• Principles of different imaging modalities: chest radiography (CXR), computed tomography (CT – including HRCT, CTA, low-dose screening), magnetic resonance imaging (MRI) of the chest, nuclear medicine scans (e.g., V/Q scans, PET-CT), and fluoroscopy.
• Systematic approaches to radiographic interpretation of the chest.
• Recognition of common and rare patterns of pulmonary, pleural, mediastinal, and cardiovascular disease on imaging.
• Understanding the indications, contraindications, risks, and benefits of different thoracic imaging studies.
• Correlation of imaging findings with clinical presentations, PFTs, and pathology results.
• Familiarity with current imaging guidelines for common conditions (e.g., lung cancer screening, pulmonary embolism, solitary pulmonary nodule evaluation).

Interpretive Skills

• Develop competence in independently interpreting chest radiographs (portable, PA/lateral) and dictating or formulating accurate reports.
• Develop advanced skills in interpreting chest CT scans, including identifying subtle findings and understanding scan protocols.
• Gain experience in the interpretation of V/Q scans, PET-CT for thoracic malignancies, and basic chest MRI findings.
• Formulate appropriate differential diagnoses based on radiographic patterns.
• Identify imaging findings that necessitate urgent clinical action.

Core Competencies

• Patient Care: Utilize chest imaging effectively for diagnosis, management, and follow-up.
• Medical Knowledge: Demonstrate a thorough understanding of thoracic anatomy, pathophysiology, and the imaging characteristics of various diseases.
• Practice-Based Learning and Improvement: Participate in radiology conferences and read-out sessions. Critically evaluate imaging literature.
• Interpersonal and Communication Skills: Communicate imaging findings clearly and concisely. Effectively consult with radiologists.
• Professionalism: Demonstrate respect for radiology staff and patients.
• Systems-Based Practice: Understand the workflow of a radiology department. Be mindful of appropriate resource utilization and radiation safety.

Evaluation

The fellow will receive a written evaluation from the supervising radiology faculty at the end of the rotation. This will assess their cognitive knowledge (interpretive skills), ability to integrate imaging with clinical data, professionalism, and communication. Areas for improvement will be discussed with the fellow and forwarded to the NMCSD Program Director.

Rotation Objectives

Clinical Knowledge and Experience

• Pathophysiology, diagnosis, and management of acute cerebrovascular disorders (e.g., subarachnoid hemorrhage, intracerebral hemorrhage, ischemic stroke).
• Management of neurotrauma (e.g., TBI, spinal cord injury), including ICP monitoring and CPP-guided therapy.
• Critical care aspects of neuromuscular disorders (e.g., status epilepticus, myasthenia gravis crisis, Guillain-Barré syndrome).
• Diagnosis and management of CNS infections and severe toxic/metabolic encephalopathies.
• Assessment of coma, herniation syndromes, hydrocephalus, and spinal cord compression.
• Principles of end-of-life care and organ donation in neurologically devastated patients.

Procedural and Technical Skills

(Familiarity with indications, contraindications, complications, limitations, and performance/interpretation under appropriate supervision)

• Advanced airway management in patients with neurological injury.
• Central venous and arterial line placement and management.
• Mechanical ventilation strategies tailored for neurocritical care patients (e.g., management of CO2 for ICP control).
• Basic interpretation of continuous EEG monitoring for seizure detection and burst suppression.
• Principles of ICP monitoring (e.g., EVD) and CPP management; interpretation of waveforms.
• Interpretation of emergent CT/MRI imaging and cerebral angiography in collaboration with neuroradiology.
• Induction and management of therapeutic temperature modulation.

Core Competencies

• Patient Care: Providing specialized critical care to patients with acute neurological conditions.
• Medical Knowledge: Acquiring detailed knowledge of neuroanatomy, neurophysiology, and specific treatment modalities.
• Practice-Based Learning and Improvement: Participating in NCC-specific M&M conferences and applying evidence-based protocols.
• Interpersonal and Communication Skills: Communicating effectively with the NCC team and families regarding complex neurological prognoses.
• Professionalism: Demonstrating sensitivity and ethical conduct in managing critically ill neurological patients.
• Systems-Based Practice: Understanding the unique resources and workflow of a specialized NCC unit.

Evaluation

The fellow will receive both oral and written feedback from UCSD NCC faculty based on cognitive knowledge, patient management skills, procedural aptitude (if applicable), and professionalism, using ACGME competency frameworks. This evaluation will be forwarded to the NMCSD Program Director.

Research Timeline

Core Competencies

• Medical Knowledge: Deepen understanding of a specific area of PCCM and learn to critically evaluate existing medical knowledge.
• Practice-Based Learning and Improvement: Develop skills in formulating research questions, designing studies, interpreting data, and applying research findings.
• Interpersonal and Communication Skills: Effectively communicate research ideas, progress, and findings through oral presentations and written work.
• Professionalism: Demonstrate integrity and ethical conduct in all research activities.
• Systems-Based Practice: Understand the institutional processes for research approval (CID/IRB) and resource utilization.

Evaluation

Fellows are evaluated monthly by their research mentor and the Program Director, focusing on progress towards research milestones, critical thinking, and development of scholarly skills.

Rotation Objectives

Clinical Knowledge and Experience

• Diagnosis and management of ARDS, severe sepsis, and respiratory failure.
• Pathophysiology and therapy of cardiovascular, renal, gastrointestinal (e.g., liver failure), neurologic, and infectious disorders in critically ill patients.
• Advanced understanding of electrolyte and acid-base disturbances.
• Critical care pharmacology in patients with organ dysfunction.

Procedural Competence

(Knowledge of indications, contraindications, complications, limitations, and proficiency under appropriate supervision)

• Advanced airway management and mechanical ventilation strategies.
• Vascular access: arterial lines, central venous catheters (ultrasound-guided).
• Diagnostic/therapeutic procedures such as thoracentesis and paracentesis.
• Hemodynamic monitoring setup, calibration, and interpretation, including POCUS.
• Understanding principles of ECMO and advanced cardiac support if encountered.

Core Competencies

• Patient Care: Leading a multidisciplinary ICU team to provide patient-centered care and communicating effectively with families.
• Medical Knowledge: Applying advanced medical knowledge to a broad range of critically ill patients.
• Practice-Based Learning and Improvement: Participating in morbidity and mortality conferences and ICU quality improvement projects.
• Interpersonal and Communication Skills: Facilitating clear and compassionate communication with patients, families, and consulting services.
• Professionalism: Upholding ethical principles and maintaining patient confidentiality.
• Systems-Based Practice: Understanding principles of organ donation and adhering to hospital regulations and clinical pathways.

Evaluation

The fellow will receive a written evaluation from Scripps faculty at the conclusion of the rotation, assessing cognitive knowledge, patient management, procedural skill, and professionalism based on ACGME competencies. The evaluation will be forwarded to the NMCSD Program Director.

Rotation Objectives

Critical Care Techniques and Procedures

• Advanced airway maintenance and ventilator management.
• Comprehensive strategies for liberation from ventilatory support.
• Diagnosis and management of various shock states using hemodynamic data and POCUS.
• Calibration, operation, and interpretation of advanced hemodynamic monitoring systems.
• Interpretation of complex imaging studies in critically ill patients.

Instrumentation and Advanced Procedures

(Exposure to and/or performance under supervision)

• Laryngoscopic (direct and video) and bronchoscopic intubation.
• Central venous catheter and arterial line insertion.
• Swan-Ganz catheter insertion and detailed hemodynamic interpretation (if utilized).
• Tube thoracostomy, diagnostic bronchoscopy, paracentesis, and thoracentesis.
• Management of various dialysis modalities (intermittent hemodialysis, CRRT).

Clinical Knowledge and Experience

• In-depth understanding of the pathophysiology and therapy for a broad range of critical illnesses.
• Management of the immunocompromised patient (e.g., post-transplant, neutropenic sepsis).
• Principles of toxicology and management of severe overdoses.
• Advanced pharmacokinetics, management of sedation, analgesia, and delirium in the ICU.

Evaluation

The fellow will receive a written evaluation from UCSD faculty at the end of this rotation, addressing cognitive knowledge, patient management, procedural skills, and professionalism, based on ACGME competencies. This will be forwarded to the NMCSD Program Director.

Rotation Objectives

Clinical Knowledge and Experience

• Understand the physiologic basis of impairment and disability in patients with chronic lung disease.
• Master the principles, components, and techniques of pulmonary rehabilitation.
• Understand patient selection criteria, assessment methods, and outcome measures.
• Gain knowledge of various exercise testing modalities and their role in prescribing exercise.
• Learn to develop individualized exercise prescriptions (aerobic, strength, flexibility).
• Understand the role of education in self-management (breathing techniques, airway clearance, oxygen therapy, etc.).
• Become familiar with psychosocial assessment and interventions for anxiety and depression.

Core Competencies

• Patient Care: Performing comprehensive assessments of patients and developing individualized treatment plans.
• Medical Knowledge: Acquiring in-depth knowledge of exercise physiology and the evidence base for pulmonary rehabilitation.
• Practice-Based Learning and Improvement: Evaluating program effectiveness through outcome measures.
• Interpersonal and Communication Skills: Effectively communicating with patients and collaborating with a multidisciplinary team.
• Professionalism: Demonstrating empathy and respect towards patients with chronic disabling conditions.
• Systems-Based Practice: Understanding the role of pulmonary rehabilitation within the continuum of care for chronic lung disease.

Evaluation

A written evaluation will be provided by UCSD faculty at the end of the rotation, focusing on cognitive knowledge, patient interaction, understanding of rehabilitation principles, and professionalism. The evaluation will be forwarded to the NMCSD Program Director.

Rotation Objectives

Knowledge-Based Objectives

• Gain in-depth knowledge of the anatomy of the tracheobronchial tree, mediastinum, and pleural space relevant to interventional procedures.
• Understand the indications, contraindications, risks, benefits, and alternatives for a variety of interventional pulmonary procedures.
• Become familiar with the setup and operation of advanced instrumentation (EBUS, navigational bronchoscopy, cryotherapy, etc.).
• Enhance skills in interpreting advanced chest imaging (CT, PET-CT) for procedural planning.

Flexible Bronchoscopy and Associated Skills

• Advanced airway inspection, endobronchial biopsy, EBUS-TBNA, and transbronchial lung biopsy (TBLB).
• Use of fluoroscopy for guidance during bronchoscopic procedures.
• Management of bronchoscopic complications (e.g., pneumothorax, bleeding).

Pleural Procedures

• Ultrasound-guided thoracentesis and chest tube insertion.
• Tunneled pleural catheter placement and management.
• Medical thoracoscopy (pleuroscopy) – observation and assistance.

Exposure to Advanced Interventional Procedures

(Observe, Assist, and potentially perform basic components under direct supervision)

• Rigid bronchoscopy, central airway debulking techniques, and airway stent placement.

Evaluation

The trainee will receive a written evaluation from Scripps interventional pulmonology faculty at the end of the rotation, based on cognitive knowledge, patient management, technical procedural skills, and humanistic qualities, aligned with ACGME competencies. This evaluation will be forwarded to the NMCSD Program Director.

Rotation Objectives

Advanced Diagnostic Bronchoscopy

• Endobronchial Ultrasound (EBUS)-guided Transbronchial Needle Aspiration (TBNA).
• Radial EBUS for localization and biopsy of peripheral pulmonary lesions.
• Electromagnetic Navigation Bronchoscopy (ENB) or other guided-bronchoscopy techniques.
• Cryobiopsy for interstitial lung disease diagnosis (exposure and potential participation).

Therapeutic Bronchoscopy

(Exposure to principles and techniques)

• Rigid bronchoscopy for central airway obstruction or massive hemoptysis.
• Management of central airway obstruction using various modalities (laser, APC, cryotherapy, stenting).
• Bronchial thermoplasty and endobronchial valve placement (understanding principles and patient selection).

Pleural Procedures

• Advanced pleural ultrasonography.
• Tunneled indwelling pleural catheter (TIPC/IPC) placement and management.
• Medical thoracoscopy (pleuroscopy) for diagnosis and pleurodesis.
• Management of complex pleural infections and empyema.

Evaluation

The trainee will receive a written evaluation from UCSD IP faculty at the end of the rotation, based on direct observation of clinical and procedural skills, contributions to patient management, and professional conduct. This evaluation will be forwarded to the NMCSD Program Director.

Rotation Objectives

Clinical Knowledge and Experience

• Master the indications, contraindications, and selection criteria for lung transplantation.
• Gain in-depth knowledge of immunosuppressive regimens (induction, maintenance, rescue therapy).
• Recognize and manage common early and late complications after lung transplantation.
• Manage primary graft dysfunction, acute cellular rejection, and antibody-mediated rejection.
• Understand and manage chronic lung allograft dysfunction (CLAD), including BOS and RAS.
• Manage infections (bacterial, viral, fungal, opportunistic) in immunocompromised hosts.
• Understand the principles of allograft surveillance, including PFTs, bronchoscopy with biopsy, and imaging.
• Familiarity with UNOS/OPTN policies and the lung allocation score (LAS) system.

Core Competencies

• Patient Care: Provide comprehensive, patient-centered care to individuals with complex advanced lung disease.
• Medical Knowledge: Acquire specialized knowledge in transplant immunology, pharmacology, and infectious diseases.
• Practice-Based Learning and Improvement: Participate in transplant program M&M and selection committee meetings.
• Interpersonal and Communication Skills: Communicate effectively with patients facing life-threatening illness and a large, multidisciplinary team.
• Professionalism: Demonstrate ethical conduct and sensitivity to the psychosocial impact of transplantation.
• Systems-Based Practice: Understand the complex organization of a transplant program, including regulatory requirements and insurance issues.

Evaluation

The fellow will receive a written evaluation from UCSD transplant pulmonology faculty at the end of the rotation, assessing cognitive knowledge, clinical decision-making, patient management skills, and professionalism. This will be forwarded to the NMCSD Program Director.

Rotation Objectives

Clinical Knowledge and Experience

• In-depth understanding of the classification, pathophysiology, and natural history of PH (WHO Groups 1-5).
• Comprehensive diagnostic evaluation for pulmonary vascular diseases.
• Principles of risk stratification in pulmonary arterial hypertension (PAH).
• Detailed knowledge of current medical therapies for PAH (prostacyclins, ERAs, PDE5i, sGC stimulators).
• Specific management strategies for CTEPH, including surgical evaluation for PTE, balloon pulmonary angioplasty (BPA), and medical therapy.
• Understanding the critical care aspects of patients with severe PH, including management of right heart failure.

Procedural and Interpretive Skills

(Knowledge, interpretation, and performance under appropriate supervision)

• Performance and interpretation of right heart catheterization, including vasodilator testing.
• Interpretation of advanced imaging: echocardiograms, V/Q scans, CT angiography for PE and CTEPH.
• Management of advanced delivery systems for PH-specific medications (e.g., continuous IV/SQ infusions).
• Application of general critical care procedures in patients with severe PH, understanding the unique risks.

Evaluation

The fellow will receive a written evaluation from UCSD Pulmonary Vascular faculty at the end of the rotation, assessing cognitive knowledge, clinical decision-making, procedural skills (if applicable), professionalism, and communication. This evaluation will be forwarded to the NMCSD Program Director.

Rotation Objectives

Clinical Knowledge and Experience

• Principles of Advanced Trauma Life Support (ATLS) and initial trauma resuscitation.
• Management of traumatic brain injury (TBI), spinal cord injuries, thoracic trauma, and abdominal trauma.
• Resuscitation and critical care of patients with major burns, including fluid management and inhalation injury.
• Diagnosis and management of shock (hemorrhagic, distributive) in trauma patients.
• Principles of massive transfusion protocols and management of coagulopathy in trauma.
• Nutritional support and advanced pain management in the trauma/burn ICU.

Procedural and Technical Skills

• Advanced airway management in trauma patients (RSI).
• Chest tube insertion (thoracostomy).
• Central venous and arterial line placement (ultrasound-guided).
• Management of invasive mechanical ventilation in complex trauma/burn patients.
• Critical care ultrasonography (E-FAST, RUSH exams).

Evaluation

A written evaluation from ARMC trauma/critical care faculty will be provided at the end of the rotation, assessing cognitive knowledge, patient management skills, procedural competency, professionalism, and communication. This will be forwarded to the NMCSD Program Director.

Rotation Objectives

Clinical Knowledge and Experience

• Diagnosis and management of common obstructive lung diseases (especially COPD).
• Evaluation and workup of pulmonary malignancies, including screening programs.
• Management of pulmonary infections, including tuberculosis and fungal infections.
• Recognition and management of occupational and environmental lung diseases prevalent in veterans (e.g., asbestosis, deployment-related respiratory issues).
• Management of sleep-disordered breathing within the VA system’s resources.

Core Competencies

• Patient Care: Providing culturally sensitive and patient-centered consultative care to veterans.
• Medical Knowledge: Expanding knowledge of diseases prevalent in the veteran population and VA-specific treatment guidelines.
• Practice-Based Learning and Improvement: Utilizing the VA’s Computerized Patient Record System (CPRS).
• Interpersonal and Communication Skills: Effectively communicating consultative recommendations to VA primary teams.
• Professionalism: Demonstrating commitment to serving the veteran population with integrity and compassion.
• Systems-Based Practice: Gaining a deep understanding of the VHA healthcare system, its benefits, and limitations.

Evaluation

A written evaluation from VA supervising faculty will be provided at the rotation’s end, assessing cognitive knowledge, patient management skills, professionalism, and understanding of the VA system. This will be placed in the fellow’s permanent file at NMCSD.

Rotation Objectives

Clinical Knowledge and Experience

• Normal sleep physiology, sleep architecture, and standard sleep staging (AASM rules).
• Pathophysiology, diagnostic criteria, and management of sleep-disordered breathing (OSA, CSA), insomnia, hypersomnias (narcolepsy), circadian rhythm disorders, parasomnias, and sleep-related movement disorders (RLS).
• Impact of sleep disorders on physical, cognitive, and emotional functioning.

Diagnostic and Therapeutic Skills

• Ordering and interpreting in-laboratory PSG, HSAT, MSLT, and MWT.
• Principles of PAP therapy: indications, proper mask fitting, troubleshooting adherence, and interpreting download data.
• Understanding indications for oral appliance therapy and surgical options for OSA.
• Cognitive Behavioral Therapy for Insomnia (CBT-I) principles.
• Pharmacologic management of various sleep disorders.

Evaluation

A written evaluation from Scripps sleep medicine faculty, assessing cognitive knowledge (especially sleep study interpretation), clinical management skills, professionalism, and communication, will be provided at the end of the rotation and forwarded to the NMCSD Program Director.