Our Pulmonary and Critical Care Division has just finished a complete renovation of the bronchoscopy suite at the University of Maryland Medical Center. The suite has state of the art video bronchoscopic equipment and a dedicated fluoroscopic C-arm. The Division performs over 900 bronchoscopy procedures each year at UMMC, and approximately 200 yearly at the VA. Our large volumes enable fellows to become proficient in all aspects of diagnostic bronchoscopy.
A particular focus of our Division is diagnostic and staging transbronchial needle aspiration (TBNA). This service is supported by referrals from the Thoracic Oncology Program and from private physicians from around the state. Fellows begin performing TBNA early in the first clinical year and learn to apply the technique for biopsy of mediastinal and hilar lymph nodes as well as peripheral masses and "coin" lesions using fluoroscopic guidance. The large volume of TBNA procedures performed at the University of Maryland is truly one of the fellowship's strengths.
Although our extensive experience with TBNA increases the diagnostic accuracy for cases of malignancy and invasive infection, some lesions are too small to visualize with routine fluoroscopy or are in technically difficult locations. At most centers these lesions are approached with surgery or percutaneous biopsy. The University of Maryland is one of a few centers with the capability to perform bronchoscopy with TBNA under CT fluoroscopic guidance. Faculty and fellows within our division have published this experience and presented data at international meetings. The procedure is performed with the patient in the CT suite. Using CT fluoroscopy, real time trans-axial imaging is obtained and used to direct the biopsy materials to the target lesion. Nodules as small as 8 mm have been biopsied successfully.
Bronchoscopy with endobronchial ultrasound (EBUS) has been gaining in popularity over the past five years as a technique with a high level of accuracy for diagnosing malignant and non-malignant disorders of mediastinal and hilar lymph nodes. Our Division has become very proficient with EBUS over the past several years and we currently perform approximately 100 of these procedures at UMMC yearly. Fellows have ample opportunity to develop proficiency with EBUS throughout their fellowship training, and this will no doubt continue as this procedure becomes more and more routine in the diagnostic evaluation of pulmonary and mediastinal disorders.
The MASTRI Center (Maryland Advanced Simulation, Training, Research and Innovation) at the University of Maryland is an innovative, research-driven, high-technology, state-of-the-art training center. Its goals are to lead in evaluation development and testing in regard to emerging simulation technologies and techniques and in the ongoing transformation of surgery and other medical procedures. Additionally, the Center is envisioned as a premier educational environment devoted to the training of healthcare practitioners across a diverse spectrum, with particular focus on how users learn and adapt to new technologies.
Our pulmonary fellows have the opportunity in the MASTRI center to participate in simulation models for diagnostic bronchoscopy (including simulation of forceps biopsy and TBNA), endobronchial ultrasound (EBUS), chest tube insertion, and use of video laryngoscopy as an intubation technique (Glide scope). The bronchoscopy simulation software is quite realistic, and represents a major learning tool for the fellows as they develop proficiency with this procedure.
Trauma Anesthesia Rotation
Trauma Anesthesiology is a Section of the Maryland R Adams Cowley Shock Trauma Center, and includes 12 attending anesthesiologists and 20 CRNAs. This section performs more than 6,000 intubations each year, and is the only group of anesthesiologists in the country with a practice focused specifically on traumatic injury. The Section trains 25 residents each year rotating in one-month blocks from the University of Maryland, Johns Hopkins, and the three Armed Services.
For the past three years, this one month rotation has become standard in our Fellowship Program at the beginning of fellowship training. During this rotation, the fellow learns basic and advanced airway management skills under the direct supervision of a Trauma Anesthesiologist. Most of our fellows who have participated in this rotation have performed 50-60 intubations in this one month time frame either in the operating room or in the Trauma Resuscitation Unit. Fellows and practicing clinicians in pulmonary and critical care medicine are increasingly expected to have substantial proficiency in endotracheal intubation and airway management. This rotation creates a foundation of airway management skills which the fellow can build upon during their many subsequent critical care rotations at UMMC and at the VA Medical Center.
The University of Maryland has a Cadaver Lab which is a component of the University of Maryland Medical School and the Office of the Medical Examiner. Approximately twice yearly, we conduct a training session in the Cadaver Lab centering on airway management techniques, including traditional direct laryngoscopy, percutaneous cricothyroidotomy, and surgical cricothyroidotomy. The training sessions also focus on pleural space management, including standard tube thoracostomy and percutaneous pigtail catheter placement. These sessions allow the fellow to develop proficiency in these techniques with direct faculty teaching and supervision.
The Sleep Disorders Center at the University of Maryland is a multidisciplinary center performing comprehensive clinical and laboratory evaluation of patients with a variety of sleep disorders. Under the direction of Steven Scharf, MD, a member of our Division and a board certified pulmonary and sleep specialist, specialists from diverse fields including ENT, Psychiatry, Dentistry, Neurology and Pediatrics, evaluate and manage a wide variety of pulmonary and non-pulmonary sleep disorders. The center maintains an outpatient clinic and a sleep laboratory. Fellows have the opportunity to rotate through the outpatient sleep center, engage in research projects linked to sleep disorders and develop clinical skills necessary for the management of sleep disordered breathing within the framework of a pulmonary medicine practice.
For more information on the Sleep Disorders Center at Maryland, click here.
Four years ago, a pulmonary and critical care medicine inservice examination was developed by members of the American College of Chest Physicians, the American Thoracic Society, and the Association of Pulmonary and Critical Care Medicine Program Directors (APCCMPD). This examination is a 125 question exam which is designed to allow fellows and fellowship programs to evaluate their knowledge base on a yearly basis.
For the past three years, we have been administering this examination to our fellows in the spring of each year. Following completion of the exam, each fellow's score is reported to the Program Director and to the fellow, and the APCCMPD provides data which allows each fellow to assess their performance in comparison to other fellows from around the country. We have found this to be a successful learning tool in our program, and an educational mechanism that allows us to ensure that our overall fellowship curriculum is current and comprehensive.