Pulmonary Consult Service
The University of Tennessee Medical Center in Knoxville is a 710-bed hospital, Level 1 Trauma Center, serves as a tertiary referral center for East Tennessee, and parts of Kentucky and North Carolina. The pulmonary consult team consists of an attending, fellow, and typically a resident. There is ample exposure to a wide range of pulmonary pathology, including infections, malignancies, pleural diseases, obstructive lung disease and pulmonary hypertension, to name a few. Additionally, the pulmonary consult service acts as the admitting and primary service for all cystic fibrosis patients that are treated in the hospital. When on the consult service, fellows are also responsible for all procedures that are undertaken on inpatients, including bronchoscopy, thoracentesis, thoracostomy tube placement, indwelling pleural catheter placement, and others. Supervision is provided by a range of pulmonary attendings who each use their expertise or interest in particular subspecialities of pulmonology to provide instruction to the fellow.
Outpatient and Continuity Clinics
Fellow Continuity Clinics
Fellows attend a general pulmonary continuity clinic one half day per week, with the exception of the medical ICU and night float blocks. Fellows maintain their own panel of outpatients for whose pulmonary care they are primarily responsible, with clinic faculty serving in a supervisory capacity to assist with diagnostic and therapeutic decisions.
In addition to their own continuity clinic, fellows attend half day clinic at subspeciality clinics when on elective blocks. Available clinics include thoracic oncology, pulmonary hypertension, interstitial lung disease, cystic fibrosis, and sleep medicine. Valuable experience is gained through exposure to these specialized fields within pulmonology, and there is opportunity for the fellows to elect to gain more experience with a particular subspeciality to narrow the focus of their career trajectory, if so desired.
The quality of critical care training provided is an important strength of the program. The presence of a 20-bed Medical ICU, a 24-bed cardiovascular ICU, a 24-bed neurocritical care unit, and a 32-bed trauma ICU, as well as the hospital's status as a major referral center affords ample opportunity for exposure to a broad range of pathology. The primary teaching team consists of an attending, a fellow, a resident, and two interns. When on the ICU rotation, the fellow acts in a junior attending role, supervising residents, and interns. The medical critical care team is typically the primary service on cardiovascular patients as well, thus providing an avenue for gaining familiarity with cardiovascular critical care. The medical critical care team also takes care of most patients on V-V and V-A ECMO. There is a dedicated night float block, during which the fellow, along with two residents, is responsible for the entire medical critical care census, and staff’s overnight admissions to the ICU. Fellows also rotate through the neurocritical care and trauma ICU on elective blocks later in training.
Extensive procedural experience is assured, including placement of central and arterial lines, temporary hemodialysis catheters, small and large bore chest tubes, paracentesis, lumbar puncture, thoracentesis, and bronchoscopy, to name a few. Fellows perform all intubations on critically ill patients during the day.
In addition to obtaining proficiency in the use of point-of-care ultrasound (POCUS), the fellowship provides comprehensive training for fellows interested in sitting for the Examination of Special Competence in Critical Care Echocardiography (CCEeXAM*), administered by the National Board of Echocardiography (NBE).
There is a monthly Advanced Ultrasound Corner session PLUS several advanced ultrasound cases are thoroughly discussed each week in our internal chat room.
The advanced SimMan at our UT center for advanced medical simulation offers multiple cardiac modules which provide additional training in image acquisition and interpretation.
On the general floors and ICUs our fellows have access to three GE Venue Go ultrasound machines. These machines provide state-of-the-art ultrasound images and analysis. There are 2 additional Sonosite M-Turbo machines for less complex evaluations.
The number and breadth of procedures that fellows perform during their training is considered one of the strengths of the program. Working with our board-certified interventional pulmonologists and our advanced diagnostic and therapeutic bronchoscopists, the fellows have access to a robust training and exposure to a variety of bronchoscopic procedures.
Fellows become proficient in flexible bronchoscopy, linear & radial endobronchial ultrasound (EBUS), fluoroscopy guided transbronchial biopsy, transbronchial cryobiopsy, transbronchial needle aspiration, navigational bronchoscopy, robotic bronchoscopy, tumor debridement, gold probe & APC electrocautery, and cryotherapy. Exposure to rigid bronchoscopy, treatment of central airway obstruction, airway stenting, endobronchial valve placement for emphysema and persistent airleak is also gained under the guidance of our expert faculty. When requested, rapid on-site cytopathology (ROSE) is readily available.
In addition, fellows will become proficient in pleural disease management through multiple pleural procedures, including thoracentesis, small and large bore chest tube placement, and indwelling pleural catheter placement.
Another highlight of our fellowship program is the unique procedural experience to perform right heart catheterizations (RHCS) for both inpatient and outpatient cases. Our group performs approximately 60-80 RHCs in the cardiac cath lab per year. These procedures are part of the evaluation of patients with dyspnea of unknown origin, pulmonary vascular disease and pulmonary hypertension, diastolic dysfunction, congenital heart disease, kidney transplant evaluation/fistulas (high output states), and other etiologies. In addition to obtaining baseline diagnostic hemodynamics, additional maneuvers learned include fluid challenge, exercise challenge, vasodilator challenge (nitric oxide, nitroglycerin and nitroprusside), comprehensive shunt run testing, transient fistula occlusion, bubble study and more.
The opportunity to perform RHCs nicely complements the clinic and hospital exposure to pulmonary vascular disease and allows the fellows to develop expertise in cardiopulmonary physiology and pulmonary manifestations of heart disease.
Fellows spend four weeks on outpatient sleep medicine during the first year of training, during which they will participate in the initial assessment and ongoing management of patients with conditions such as central & obstructive sleep apneas, parasomnias, etc. Fellows learn about the fundamentals of reading sleep studies, and gain familiarity with the management of CPAP machines, hypoglossal nerve stimulators, and other modalities of treatment.
Pulmonary Rehab/Applied Physiology
Fellows spend one block on this combined rotation, during which they attend the outpatient pulmonary rehab center with the goal of becoming familiar with the indications and protocol of pulmonary rehab. Furthermore, fellows spend time at the PFT lab, working with respiratory technicians as they perform PFTs and cardiopulmonary exercise testing on outpatients.
One block during the first year is dedicated to cardiothoracic surgery; fellows see inpatient consults with cardiothoracic surgeons and have the opportunity to observe or scrub in on thoracic surgeries, including VATS and open thoracotomy.