Surgical Critical Care at DHMC
Denver Health Medical Center (DHMC), formerly known as Denver General Hospital, is the Rocky Mountain Region’s academic Level I trauma center, and the safety net hospital for metropolitan Denver. The Denver Health system, which integrates acute and emergency care with public and community health, includes Denver Public Health, the Rocky Mountain Regional Trauma Center, the Denver Health Paramedic Division, Denver's 911 emergency medical response system, the Rocky Mountain Poison and Drug Center, and the Rocky Mountain Center for Medical Response to Terrorism, Mass Casualties and Epidemics.
DHMC is an American College of Surgeons Committee on Trauma verified, state certified, Level I trauma center with more than 3,800 trauma admissions annually, including more than 650 patients with an injury severity score greater than 15. DHMC has one of the best survival rates in the nation; the overall survival rate for blunt trauma is 96 percent, and for penetrating trauma 86 percent. The trauma team, comprised of world-renowned trauma/acute care surgeons, emergency medicine physicians, neurosurgeons, plastic surgeons, anesthesiologists, radiologists, orthopedists and urologists, as well as outstanding trauma and critical care nurses, care for more than 2,000 of the region’s most severely injured patients each year. The Trauma Center at DHMC has two helipads, ED resuscitation suites, 12 OR rooms, and 20 ICU beds dedicated specifically for trauma care. A team of trauma coordinators works closely with patients, their families and physicians to ensure that the best possible care is provided to each and every patient. In addition to the care of the injured patient, the six full-time trauma surgeons also provide all of the emergent surgical care for the hospital. Therefore, the trauma/general surgery faculty has a broad experience in cervical, thoracic, vascular, abdominal, combined orthopedic, and extremity techniques from diverse etiologies.
Care in the SICU is delivered in a multidisciplinary, evidence-based, algorithm-driven approach, using NIH protocols. Six full-time academic board-certified trauma surgeons, with added qualifications in surgical critical care, are responsible for the daily care of the patients. During the 2005 year, more than 1,900 surgical patients were admitted to the intensive care unit. Among the patient care algorithms are standard protocols for trauma resuscitation, ventilator management, tight glucose control, recognition and management of adrenal insufficiency, nutrition, transfusion and infection.
The Critical Care Resident (CCR) will assume a direct role in the design and execution of treatment plans when on the SICU rotations. The critical care resident will also supervise the performance of intensive care unit procedures, including airway control, bronchoscopy, central venous, pulmonary artery and peripheral arterial line placement, tube thoracostomy, thoracentesis, arteriovenous hemofiltration, and arteriovenous rewarming. The CCR will interact with each of the attending surgeons, who retain ultimate responsibility for the management of their patients, enabling the CCR to learn various styles of critical care management. The CCR, in conjunction with the admitting general surgical team, will formulate and contribute to all diagnostic and treatment plans. The CCR will also interact with the general surgery residents in a discussion/teaching capacity during daily checkout rounds and work rounds. The CCR is responsible for conducting daily rounds with the ICU based residents, and his/her responsibilities will include patient assessment and assuring that appropriate treatment plans are designed and carried out. The CCR will also be expected to attend teaching and patient care conferences, and to organize the weekly Critical Care Teaching Conference.
Trauma & Acute Care Surgery at DHMC
The TACS rotation at DHMC incorporates all aspects of the resident training experience. Under the supervision of attending faculty members, the TACS resident will be the physician responsible for evaluation, care, and intervention of the acutely ill surgical patient. The rotation also includes coverage of surgery clinic, which evaluates patients with general surgery, thoracic, vascular, endocrine, and oncologic diseases for elective surgery. Cases evaluated in clinic by the resident will be booked for that resident’s involvement, either as primary surgeon (if the general surgery chief is unavailable) or as the teaching assistant to the general surgery team. Being on call at DHMC incorporates the evaluation of patients with trauma, critical illness, thoracic, vascular, abdominal, neurologic, and orthopedic emergencies.
Also included in these 5 months of TACS rotations is exposure to Anesthesia, Plastic Surgery, and Interventional Radiology. Involvement with the Anesthesia department facilitates overall care of the patient and provides technical exposure to routine and complex intubations. Operative cases with the Plastic Surgery faculty provide exposure and learning in such arenas as complex facial reconstructions, facial fracture management, and free flap design. Due to the significant amount of overlap and interplay between Surgery and Interventional Radiology, a dedicated experience with IR techniques and therapeutic interventions is planned. The goal of the experience is broadened exposure to the clinical decision-making involved in determining if a patient warrants IR versus surgical intervention, the role of IR techniques, and the complications associated with such measures. Additionally, the TACS resident should have additional exposure to routine bedside procedures and body imaging.
Exposure and responsibility for administrative tasks and teaching is a mandatory requirement of these rotations but should also be pursued throughout the TACS Fellowship years. Administrative exposure is attained through such conferences and meetings as the Interdisciplinary Care Committee, Trauma Service Line, RETAC, and SEMTAC. Teaching of residents and students is inherent in bedside rounds, the operating room, and clinical conferences. In particular, the resident will be expected to lead M&M conference at least once a month. Additionally, the TACS resident is strongly encouraged to become an ATLS instructor during the first year of the fellowship and teach during subsequent months of the training program. Additional exposure to teaching and education of others is available through the DHMC Outreach Program; the TACS resident may volunteer to give lectures at outside facilities on a wide range of trauma, critical care, and emergent case topics.
The TACS resident is expected to engage in academic pursuits. A month-long research elective is available to encourage dedicated time to clinical research projects and authoring review articles. Over the 2-year training program, abstracts for at least 2 national meetings and associated participation in manuscript drafting under faculty mentorship is advocated.
At the completion of the fellowship training, the graduate will have demonstrated proficiency in the medical management and operative treatment of hemorrhage, infection, inflammation, perforation, laceration, obstruction and fractures. They should also master the technical skills necessary to manage the complex or multiply-injured patient, including operative intervention. They will also assume gradated responsibility in the role of “lead-surgeon” in all management arenas: ICU, trauma bay, resuscitation suite, clinic, IR, and OR.
Burn/Cardiothoracic/Surgical Critical Care at UCHSC
The University of Colorado Hospital is the Rocky Mountain’s regional academic medical center, and has been consistently ranked as one of America's best hospitals, according to U.S. News & World Report. University of Colorado Hospital is also the region’s leader in tertiary and referral-based care. The Department of Surgery at UCHSC incorporates general, hepatobiliary, oncologic, transplant, cardiothoracic, breast, and endocrine surgical disciplines. The UCHSC Burn Unit is the regional burn center verified by the American College of Surgeons and American Burn Association, serving the state of Colorado and the surrounding region. With more than 175 admissions per year, the Burn Unit provides emergent, acute, and rehabilitative services for this patient population including all follow-up and referral care.
The goal of the Burn Unit rotation at UCHSC to develop an understanding of the current concepts of burn pathophysiology and apply this information in the evaluation, resuscitation, clinical management, and rehabilitation of the burned patient. Emphasis will be placed on burn resuscitation and physiology, ventilator management in the setting of systemic inflammation accompanying burns and thermal airway injury, and nutritional support. The CCR will function as an integral component to the burn service in conjunction with the general surgery resident on the burn service and the burn attending. Responsibilities will include attending daily rounds in the burn unit, formulating and executing critical interventions, and monitoring patients. In addition, the CCR will be expected to attend multidisciplinary patient care and teaching conferences.
The goal of the rotation on the Cardiothoracic/Surgical Intensive Care rotation is to develop a clear understanding of pre-and post-operative management of the cardiac surgical patient. Emphasis will be placed on the pathophysiology and support of heart failure, diagnosis and treatment of arrhythmias, and use of vasoactive medications in the ICU setting. The CCR will function as an integral member of the cardiothoracic service in conjunction with the cardiothoracic surgery fellow, the general surgery residents, and attending cardiothoracic surgeons. Responsibilities will include attending daily rounds in the SICU and CCU, formulating and executing critical interventions, and monitoring patients. In addition, the CCR will be expected to attend multidisciplinary patient care and teaching conferences.
Pediatric Critical Care at The Children’s Hospital
The CCR will rotate in the Pediatric Intensive Care Unit (PICU) at The Children’s Hospital as a member of the Pediatric Surgery/Pediatric ICU team. This rotation will focus on critical care issues related to neonates, infants and children in the setting of trauma and postoperative general surgery. Emphasis will be placed on ventilatory and hemodynamic support, fluid and electrolyte management, and nutritional support. The CCR will gain an understanding of the age specific requirements of pediatric critical care through participation in daily ICU rounds with the pediatric surgery fellow, general surgery residents, and the pediatric attending surgeons. During this rotation, the CCR will also work closely with the pediatric intensivists and pediatric residents rotating in the PICU.
Thoracic Surgery at the UCH/VAMC
The goal of the Thoracic Surgery rotation is for the fellow to be comfortable and competent in the diagnosis of, operative techniques, and postoperative care and complications of patients with thoracic maladies. Emphasis will be placed on broadening the knowledge base acquired as a general surgery residents as well as refining associated techniques. The TACS resident will function as an integral member of the service in conjunction with attending surgeons. By the end of the rotation, the resident should be able to demonstrate the ability to effectively manage thoracic disease. Responsibilities will include attending daily rounds, formulating management plans, assisting/performing operations, and covering call for emergencies. In addition, the resident is expected to attend multidisciplinary patient care and teaching conferences.
Vascular Surgery at St. Joseph’s Hospital
The goal of the Vascular Surgery rotation is to develop a clear understanding of pre and post-operative management, as well as intraoperative techniques and decision-making of the patient with vascular disease. Emphasis will be placed on the diagnosis and treatment of acute ischemia, evaluation of vascular trauma, and operative reconstruction techniques. The TACS resident will function as an integral member of the service in conjunction with attending surgeons. Responsibilities will include attending daily rounds, formulating and executing critical interventions, assisting/performing operations, and covering call for vascular emergencies. In addition, the resident is expected to attend multidisciplinary patient care and teaching conferences.
Hepatobiliary/Transplant at UCH
The goal of the rotation on the Transplant service is to educate the TACS resident in all aspects of hepatobiliary problems, injuries, and operative techniques. The resident will have graduated responsibility and increasing exposure to the technical aspects of care. The clinical experience will be augmented by daily conference attendance, concentrating on review of the conditions encountered by the care team as well as various conditions.
Neurosurgery at DHMC
The goal of the Neurosurgery rotation is to gain experience in patients with traumatic brain and spine injuries, including appropriate monitoring techniques. The rotation will concentrate on the initial examination, diagnosis, and treatment of these conditions, and appropriate referral of such conditions to specialists when appropriate. The resident will have graduated responsibility and increasing exposure to the technical aspects of care. The clinical experience will be augmented by daily conference attendance, concentrating on review of the conditions encountered by the care team.
Orthopaedics at DHMC
The goal of the Orthopaedics rotation is to educate the resident in all aspects of musculoskeletal conditions and skeletal trauma that are typically encountered in the emergent or urgent care setting. The rotation will concentrate on the initial examination, diagnosis, and treatment of these conditions, and appropriate referral of such conditions to specialists when appropriate. This rotation builds on the foundation of experience gained during the General Surgery PGY-I orthopaedic rotation. The TACS resident will have graduated responsibility and increasing exposure to the technical aspects of care. The clinical experience will be augmented by daily conference attendance, concentrating on review of the conditions encountered by the care team as well as various orthopaedic conditions.