Overview of Clinical Rotations

In-Patient Cardiology Service

(Under the direction of Dr. Armsby, staffed by Drs. Armsby, Balaji, Holmes, Huang, Kelly, Madriago, Minette, Ronai, Shaughnessy, Silberbach as well as cardiac intensivist McCammond)

A fellow is assigned to the in-patient Cardiology Service for two weeks. The in-patient service includes cardiology and CT surgery patients on the pediatric ward, pediatric intensive care unit (PICU), and neonatal intensive care unit. Consultations are also covered throughout the clinics, wards, ICUs and ED. 

The in-patient Cardiology Service team includes a pediatric cardiology fellow, attending (rotating weekly), resident, and/or medical students, and nurse practitioners. In-patient rounds begin in the PICU at 7:30am. Ideally the fellow will have seen the patients and reviewed the overnight events prior to rounds. Rounds are multidisciplinary and involve the CT surgeon, PICU attending and residents, cardiology attending and fellow, nursing, pharmacy, social services, discharge planning and others. The PICU resident presents each patient on rounds, the fellow listens to the presentations, corrects or emphasizes data, provides a more thorough explanation of echo or cath findings and assists the resident in creating an assessment and plan. The exception to this is that for critically ill patients, or neonates, on the morning following the first post-operative night the fellow will present the patient. With time and experience the fellow will be given an increasing role in making the primary decisions involved in patient care and leading cardiac PICU/NICU rounds. 

At the conclusion of rounds the fellow presents a brief summary of the patient going to surgery on that date. This includes a brief history, summary of pertinent pre-operative data, indications for surgery, planned operation and potential issues post-operatively. 

Consults coming in throughout the day are seen first by the fellow and/or medical student and subsequently with the faculty. 

Fellows are encouraged to become the primary cardiologist for new patients on the inpatient service. Whenever possible these patients are followed by the fellows in their continuity clinics.

Echocardiography

(Under the direction of Dr. Madriago and staffed by Drs. Holmes, Huang, Kelly, Minette, Ronai, Shaughnessy and Silberbach)

The echocardiography lab is staffed by eight faculty and seven technicians. The lab performs ~ 5000 transthoracic, 200 transesophageal and 300 fetal echos per year. The fellows learn echo in various settings, including echo rotations, night and weekend call, catheterization procedures (device placement), Medical/Surgical conference preparation and presentation of studies, elective rotations and research. Fellows learn the difference between adequate and incomplete studies, and develop the skills to interpret and communicate the results of studies to patients, physicians and cardiac surgeons. 

The echo rotations provide hands-on training, supervised by technicians who are exceptional and enthusiastic teachers. The specific learning objectives during these rotations include an understanding of the indications for echo, the pertinent data to be collected in each type of study, the physical principles of image formation and flow velocity measurements, and the technical skills necessary to obtain high quality images.

By the end of the first several echo rotations, the fellows will be able to independently perform a complete standard pediatric study. Early on the fellows are expected to perform a minimum of two studies per day, this number increases with experience. In addition, the fellow is expected to read (with the attending staff) each of his/her studies performed during the day. Once the skills of transthoracic echo are substantially developed, the fellows will have an increasing role in TEE and fetal studies. All studies done during call will be supervised by either an echo technician or faculty, until the fellow is independently performing these studies at a high level. The studies are all reviewed by the fellow and echo staff the following morning. 

A valuable educational experience involves the preparation and presentation of echos at the weekly Medical/Surgical conference. The fellow reviews all studies to be presented at conference with the echo attending assigned each week. Relevant images are selected and presented at the conference in preparation for surgery.

Cardiac Catheterization

(Under the direction of Dr. Grant Burch;staffed by Drs. Burch and Armsby)

The program has a dedicated pediatric cardiac catheterization laboratory, which schedules patients 4-5 days per week. The interventional faculty have expertise and experience in all aspects of post-natal interventional cath. All fellows perform a minimum number of procedures (50) recommended for board eligibility, beyond that the number of procedures is determined by the fellow's level of interest. 

First year fellows are assigned a rotation in the cardiac catheterization laboratory early in the first year. The rotation is intended as a closely supervised orientation. A second rotation, designed for concentrated training at a higher level, is scheduled later in the first year. Fellows may use elective time for additional intensive experience in the cath lab. Beyond these rotations fellows are expected to spend approximately one day per week doing cath procedures, except during inpatient service rotations. During those months, the fellow is given first priority toward participating in catheterizations performed on in-patients. 

In addition to performing the catheterization, the fellow is expected to be involved in the pre- and post-catheterization management of the patient and to obtain informed consent from the parents. Prior to the procedure, the fellow should review the available data to formulate an understanding of the indication for catheterization, the data to be collected, and have developed a plan for the procedure itself. With increasing experience and exposure to the procedures, the fellow will be expected to become adept at the basic skills involved. Following the procedure, the fellow is expected to review and interpret the angiograms, interpret the hemodynamic data, calculate flows, shunts and vascular resistances and present the data at the medical/surgical conference.

Elective Rotations These rotations are designed by the fellow and program director according to the fellows' interests and needs. Electives are often utilized to provide intensive clinical experience, explore research interests, identify mentors or –in the second or third years –to complete research projects initiated earlier. The fellow and program director meet prior to the elective to design a meaningful and productive rotation.VI. 

Electrophysiology The electrophysiology experience is not organized into a single rotation. EP conferences and one-on-one teaching sessions with Dr. Balaji, are given every six weeks. In addition, fellows attend Dr. Balaji's general EP and Pacemaker clinics and EP procedures at intervals primarily during their elective and research months. Although the concepts and fundamentals of EP studies are presented, fellows are not routinely involved in the EP studies. Fellows gain proficiency in interpreting electrocardiograms, holter and event monitors during Inpatient service rotations, call and in their out-patient clinics. Fellows are expected to read ecgs, holters and event monitors on the iECG system.VII. 

Magnetic Resonance Imaging

Dr. Michael Silberbach provides the division with expertise in pediatric cardiac MRI. Dr. Craig Broberg, of the Adult Congenital Division, is also expert in cardiac MRI. 

Out-Patient Clinic

Each fellow attends Friday morning Fellows Clinic twice monthly. These clinics are staffed by two fellows and an attending cardiologist. Every effort is made to provide fellows with as many newly diagnosed CHD patients as possible, in addition, patients with whom the fellow became closely involved during their Inpatient Service months are assigned to that fellow's continuity clinic. A fellow may schedule appointments for their patients outside of their clinic date when necessary. 

We have a very busy Pediatric Cardiology Outreach Clinic program in which the attending cardiologists and echo technicians attend outreach clinics throughout Oregon on a rotating basis. Fellows are invited to attend these clinics, which provide a rich experience in managing out-patients. 

The fellows are welcome to attend the following subspecialty clinics: hyperlipidemia, aortopathy (Marfan), Turners, pulmonary hypertension, transplant, inherited arrhythmia and hypertrophic cardiomyopathy. 

Adult Congenital Heart Disease

Drs. Craig Broberg, Luke Burchill, and Abigail Khan care for a large and growing population of adult patients with congenital heart disease. This group actively participates in our weekly Medical/Surgical and Morbidity and Mortality Conferences. Our fellows assist in the cardiac catheterizations on these patients, and their surgeries are performed by our congenital CT-surgeons. The post-operative care is directed by the ACHD group at OHSU. Fellows are required to attend eight ACHD clinics during the three-year fellowship. 

On Call Responsibilities

Fellows take call from home one weeknight a week and every fourth weekend. The fellow is on first call for all parent calls, as well as for any in-house calls from the Resident Staff. Physician referral calls will be directed to the faculty attending on call. All cardiology patients being admitted to the hospital for cardiac or non-cardiac related illnesses, and any cardiac patient presenting to our emergency department with a cardiac-issue should be seen and evaluated by the on-call cardiology fellow.

The on-call fellow should remain in the PICU overnight for all neonatal surgeries, or hemodynamically unstable post-operative patients. In addition, the on-call fellow should be present at the bedside when a patient returns from the operating room, regardless of the time.  

Lastly, it is expected that the fellow on weekend call will have made rounds prior to combined rounds with the faculty attending. 

Vacation 

Each fellow receives four weeks vacation per year, to be scheduled by the fellow in 1-2 week blocks. Vacations may not be scheduled during Inpatient Service months. Only one fellow may schedule vacation at a time. In addition, fellows receive 10 days with pay annually for sick leave. This time is cumulative throughout the fellowship. The vacation, sick leave and maternity/paternity leaves are described in more detail in the Fellow Leave Policy.