Curriculum

Clinical Overview

All core rotations take place at MetroHealth Main Campus, Northeast Ohio’s leading Adult Level I Trauma Center and Pediatric Level II Trauma Center. The APP Fellow is expected to work a maximum 60-hour work week, including clinical and didactic education time.

Emergency General Surgery (10 weeks): The APP fellows will work closely with the Emergency General Surgery (EGS) attending physicians, general surgery residents, and EGS APPs to complete daily rounds on the surgical floor and intensive care unit (ICU) patients. The APP fellow is expected to work with the team to complete timely documentation and carry out care plans in a timely fashion.

This rotation also provides opportunities to develop proficiency as a surgical first assist. Common clinical cases in EGS include appendicitis, gallbladder disorders, bowel obstructions, abscesses, necrotizing soft tissue infections, hernias, hollow viscous perforations, and diverticulitis.

Trauma Surgical Floor (10 weeks): The APP fellows will work closely with the trauma APPs and trauma attendings to form disposition plans with a multidisciplinary team and respond to traumas in the resuscitation bay.

The APP fellow will be responsible for presenting his/her patients at weekly multidisciplinary rounds. This rotation provides the APP fellow with an opportunity for increased autonomy to develop a timely workflow, round on patients, develop care plans, place orders, and complete appropriate daily documentation on patients.

APP fellows are expected to develop an understanding of what injuries and complications warrant admission to the trauma service, what factors inhibit discharge, and how to determine if a patient is medically cleared for discharge as well as demonstrate professionalism in working with a multidisciplinary team.

Trauma Nights (4 weeks): The APP fellows will work with the “Night Team,” which consists of general surgery residents, medical students and a trauma attending. The fellow will work with the “Night Team” to evaluate and treat new patient consults and to develop the ability to triage patients based on level of acuity. This rotation will provide additional opportunities to develop procedural skills.

Trauma Clinic (3 weeks): Many trauma and EGS patients require follow-up care once discharged from the hospital. The APP fellow will have the opportunity to become familiar with common complications that present in the outpatient setting, outpatient care plans, and determining clearance from outpatient follow up.

Intensive Care Unit (14 weeks): The APP fellows will work closely with the Trauma ICU (TICU) team and Surgical ICU (SICU) team, which includes the trauma/critical care attending, surgical critical care fellow, general surgery resident team, and ICU nursing staff to complete daily rounds in the ICU.

At times, the APP fellow may also be responsible for responding to trauma activations in the resuscitation bay. The APP fellow is expected to further develop their understanding of the following topics while on this rotation: sedation and pain management, ventilator management, noninvasive cardiac output monitoring and volume assessment, types of shock, vasoactive infusions, and other common critical care issues.

The APP fellow is expected to develop an understanding of the following procedures, including indications and execution of: arterial blood gas, arterial line placement, bronchoscopy, central venous catheter placement, and point of care ultrasound. This rotation will provide opportunities to develop critical thinking and practice procedural skills.

Burn Surgery (2 weeks): The APP Fellow will work with the MetroHealth Burn APPs and surgeons, participating in all aspects of care of the burn patient from arrival through discharge to outpatient follow-up. This broad experience will allow the APP Fellow to see and manage these acutely critically ill patients through their initial presentation to the long-term management of complex wound healing and reconstruction. The APP Fellow will participate in assessment and resuscitation in the trauma bay and burn ICU, as well as participate in operative cases and procedures.

Electives (6 weeks): Options include, but are not limited to Surgical ICU (SICU), Burns, Neurocritical Care (NCC), Life Flight (prehospital air transport), Community Trauma/Critical Care/EGS, and Physical Medicine & Rehabilitation (PM&R)

Didactic Overview

Advanced Trauma Life Support (ATLS): This course will be sponsored by the MetroHealth Division of Trauma. Successful completion of this course is required for graduation and is expected on the APP fellow’s first attempt.

Continued Medical Education: Five continued medical education days are provided to use throughout the year for trauma, critical care, or EGS related conference attendance. Financial support for conference attendance is incumbent upon successful completion of ATLS.

Multiple self-study educational resources: The APP fellow will have access to MetroHealth’s Division of Trauma SharePoint site, which includes evidence-based practice management guidelines and landmark papers, a subscription to UpToDate, and access to the Harold H. Brittingham Memorial Library journal collection.

Friday Morning Trauma Conference [Every Friday at 7AM]: During this weekly conference, residents and fellows present patient cases and review up to date research, citing the most relevant articles. Trauma attending physicians facilitate educational and engaging conversations regarding the presented patient cases. The APP fellow is responsible for attending the weekly conferences and presenting quarterly in their Fellowship year.

Bimonthly APP Fellowship Lectures [2nd and 4th Fridays at 8AM]: These lectures are presented by trauma attending physicians and are directed toward APP education. The APP fellow must call in via WebEx if not on clinical service that day.

Weekly Morbidity and Mortality (M&M) [Every Tuesday at 7AM]: This meeting is attended by all members of the Department of Surgery and Division of Trauma. Residents present selected cases involving surgical complications or death to identify areas of improvement in patient care. The meeting provides a forum to teach quality improvement and fosters a climate of openness and discussion about surgical complications, system issues, or errors in decision making and/or communication. The APP fellow is responsible for attending the weekly conferences when on service.

Procedural Overview

  • Monthly simulation (SIM) sessions with a lecture and clinical application component
  • The following procedures are covered in quarterly SIM sessions:
    • Chest tubes (large bore, pigtail)
    • Arterial lines
    • Central lines
    • Arterial blood gas (ABG)s
    • Ultrasound (eFAST)
    • Intubation
    • Cricothyrotomy
    • Tracheostomy
    • Pelvic binder application
    • Tourniquet placement
    • Wound care (wound vacs, I&D, packing)
    • Arterial brachial index (ABI)
    • Spine immobilization (cervical spine, spine board)
  • Final SIM session is a cumulative exam to test fellow on applying clinical knowledge and procedural skills learned throughout the year

Supervision

APP fellows will be added to all trauma, surgical critical care, and EGS supervisory or collaborative agreements for PAs/APRNs. APP fellows will be supervised and mentored by trauma, surgical critical care, EGS attending physicians and APPs, surgical critical care fellows, and general surgery residents.

While the APP fellow will be supervised throughout their fellowship experience, it is expected that the fellow develops autonomy as a practicing clinician and transitions from a student mindset to an independent practicing provider who is able to collaborate with their trauma, surgical critical care, and EGS colleagues.

Fellowship Graduation Requirements:

  • Passing clinical and professionalism evaluations from attending physicians and APPs on each rotation
  • Successful completion of ATLS
  • Successful completion of quarterly procedural simulations with passing evaluations
  • Successful completion of Friday Morning Trauma Conference case presentations with passing evaluations
  • Successful completion of midterm and final clinical simulation
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