Mission

To support the warfighters who defend the constitution of the United States by developing the next generation of Army and Air Force pulmonary and critical care physicians and leaders.

Vision

Our Fellowship Program strives to be the premier training program for Pulmonary and Critical Care Medicine within the Department of Defense and provide an unparalleled innovative and practical academic environment where fellows and faculty are dedicated to lifelong learning and selfless service to our soldiers/ Airmen and their families.

Aims

• Serve as the premier training program for PCCM within the DOD.
• Provide a practical academic environment where fellows and faculty are dedicated to an intentional growth mindset and lifelong learning.
• Produce fellows who demonstrate selfless service to our soldiers/airmen and their families.
• Develop competent physicians who will be leaders in Pulmonary/Critical Care Medicine and military medicine.
• Foster a clinical environment that prioritizes safe and high-quality patient care.

Didactics are scheduled every Wednesday from 9 a.m. – 12 p.m. Tumor board is every other Thursday from 8:30 – 9:30 a.m. and every Friday, 8  – 10 a.m., we have combined academics with University of Texas Health San Antonio (UTHSA).

The majority of blocks at site 1 are two-week rotations. Outside rotations to include UH MICU, CVICU, Neuro ICU, Baptist MICU, Texas Center of Infectious Disease, Transplant, STICU, and Burn ICU are four-week rotations.

• Cardiovascular Intensive Care Unit
• Critical Care Ultrasound
• Military Unique Curriculum in Honduras (MUCH)
• Neuro Intensive Care Unit
• Nuclear Medicine
• Radiology
• Research
• Sleep Medicine Clinic
• University of Texas Health San Antonio Interstitial Lung Disease
• USNS Mercy

The call schedule various depending on which block you’re rotating on.

• Medical Intensive Care Unit (MICU) days/nights are 12 hour shifts with sign out occurring at 6 a.m. and 6 p.m.
• Outpatient-A (OPA) covers the MICU on the first Saturday of each block.
• Outpatient-B (OPB) covers the MICU on the second Saturday of each block.
• Approximately 4 times a year, a fellow is asked to cover the MICU on a Friday night, allowing the MICU night fellow a night off.
• Outside rotations (University Hospital, Baptist, Surgical Trauma Intensive Care Unit (STICU), Burn, etc…) have their respective schedules that are determined at the start of each rotation and adhere to ACGME work hour regulations.

The SAUSHEC PCCM Fellowship incorporates several military unique rotations and courses over the last two academic years, to include: a senior elective rotation aboard the USNS MERCY while conducting in humanitarian actions; a resource limited critical care rotation embedded within a large academic, safety net hospital in Honduras; and participation as the Role III intensivist in the large-scale 5-day Fort Cavazos Joint Medical Exercise. Likewise, we conduct monthly combined didactics with the other tri-service PCCM Fellowships focusing specifically on military-unique topics and professional development.

Outpatient A

1st year fellow outpatient pulmonary consults, approximately 10 weeks per academic year. A typical schedule is 2.5 days of clinic including a mixture of new patient consults, cystic fibrosis clinic, continuity clinic, and lung cancer screening. A half day is dedicated to admin time and to procedures. 

Outpatient B

2nd – and 3rd-year outpatient pulmonary consults, approximately 2-6 weeks per academic year. A typical schedule is 2.5 days of clinic, including a mixture of new consults, neuromuscular clinic, continuity clinic, and lung cancer screening. A half day is dedicated to admin and a full day to procedures.

Inpatient

Inpatient consults, 6-8 weeks per academic year. Fellows will see one half day of continuity clinic during the inpatient rotation.

BAMC Medicine ICU

10 – 12 weeks per academic year split between days and nights. Fellows are not required to see continuity clinic during MICU blocks.

Pulmonary Function Testing

Approximately eight weeks during the first year of fellowship dedicated to reading all pulmonary function testing, interpreting cardiopulmonary exercise stress testing, and providing backup for walk-in procedures. Fellows will see one half day of continuity clinic.

Radiology

Approximately four weeks during the first year dedicated to chest radiography embedded with a fellowship training thoracic radiologist.

Anesthesia

4-6 weeks during the first year dedicated to airway management in the OR with an anesthesiologist.

Sleep

4-6 weeks in the second year of fellowship. The rotation is primarily located at Wilford Hall’s 16-bed Sleep Clinic. Responsible for seeing sleep clinic, reading polysomnographies, and learning about the various modes of non-invasive positive airway pressure management.

Transplant

Four weeks during the second half of fellowship rotating at University of Texas, San Antonio’s lung transplant program. The rotation is a mixture of inpatient and outpatient consult and follow ups. One half day is dedicated to procedures.

Ultrasound

4-6 weeks of dedicated ultrasound time. Paired with a dedicated faculty, fellows will be responsible for working their way through core curriculum and developing image acquisition and interpretation skills for patients both within the inpatient and outpatient setting. Fellows will see one half day of continuity clinic.

Surgical Trauma ICU

4-8 weeks rotating through the surgical and trauma ICU at BAMC, typically either during their second or third year. Fellows oversee admitting, rounding, and either performing or staffing residents on procedures. Fellows do not see clinic during this rotation.

Burn ICU

4-8 weeks rotating through the Institute of Surgical Research Burn ICU. Fellows oversee admitting burn patients, rounding, and either performing or staffing residents on procedures. Fellows do not see clinic during this rotation.

University Hospital MICU

Four weeks during the third year of fellowship. Fellows oversee admitting, rounding, and either performing or staffing residents on procedures. Fellows do not see clinic during this rotation.

Cardiovascular ICU

Four weeks during the third year of fellowship. Fellows rotate through the cardiothoracic ICU, managing post-op heart, LVADs, and assisting with cannulating and managing patients on Extracorporeal Membrane Oxygenation (ECMO).

University of Texas Neuro

Four weeks during the third year of fellowship.

Baptist MICU

Four week rotation in a large, community ICU setting during the third year of fellowship.

On average, 20-weeks of dedicated outpatient clinic. Most of this time is spent during the first and second years. Continuity clinic is seen on a weekly basis when fellows are not on an ICU rotation.

On average, 36-40 weeks in an intensive care unit. This is split up between BAMC MICU, STICU, BURN, UH MICU, CV-ICU, Neuro ICU, and Baptist ICU.

Simulation is an important part of training for pulmonary and critical care fellows. Mastery of procedures starts in the first four weeks of fellowship with the fellow bootcamp and continues monthly for the duration of fellowship. Bootcamp: A  4-week course for first year fellows starting with tabletop discussions regarding various core pulmonary and critical care core procedures and scenarios. Fellows then progress to practicing basic skills on simulation models such as vascular access and airway management and finally incorporating these procedures into patient simulation sessions.

Annual Courses

Endobronchial Ultrasound Course (EBUS)

Two academic half days per year dedicated to EBUS training.

MD Anderson Fellow Bootcamp

Regional training course for all PCCM fellowship programs.

Continuous renal replacement therapy (CRRT)

Annual training on the initiation, management, and troubleshooting CRRT.

Ultrasound Bootcamp

Two full days dedicated to the basics of ultrasound and advanced point of care ultrasound. Combined with UTSA PCCM fellowship.

Airway Course

Joint training with trauma/cc, anesthesia, and PCCM in advanced airway management in the critical care setting.

Monthly Simulation Sessions

As part of the BAMC PCCM academics, monthly simulation sessions are dedicated to practicing high risk but low volume procedures and/or clinical scenarios. Sessions include a tracheostomy management, airway bleed, massive gastrointestinal bleed, and intracranial pressure monitoring.

Recognizing that our graduates are placed in leadership roles in their initial assignments, leadership principles are regularly discussed in our conferences. Recently, we have begun the development and integration of a dedicated curriculum has been establish to facilitate their development as junior leaders.

Our fellows have an opportunity to hold leadership positions within our program, such as chief fellow, as well as within SAUSHEC GME (house staff officer, resident membership on all GME subcommittees, etc.).

Research is a core part of PCCM fellowship. Currently there are five large, funded research projects to include:

• CHILL: Multisite randomized clinical trial assessing the benefit of therapeutic cooling for the management of acute respiratory distress syndrome.
• STAMPEDE: Multisite, multimodal assessment of service members returning from Southwest Asia complaining of chronic respiratory symptoms.
• Active duty COVID: multimodal assessment of service members complaining of chronic respiratory symptoms after a COVID-19 infection.
• SIPE: a comprehensive assessment of service members suffering from swimming induced pulmonary edema (SIPE).
• Lung Features: Lung ultrasound acquisition to build an AI powered tool for battlefield medics to assist with rapid assessment of pulmonary disease.
• NEUTRALIZE-AKI: Selective activated neutrophil removal for distributive shock and acute kidney failure.

Other areas of research include: ECMO, point of care ultrasound, lung cancer screening and staging, chronic dyspnea, ketamine in the using of procedural sedation, bronchoscopy, and many more.

Each fellow is given the opportunity to attend and present at all the major conferences to include American College of Chest Physicians (CHEST), American Thoracic Society (ATS), Society of Critical Care Medicine (SCCM), Military Health Research Symposium (MHSRS), and Tri-Service American College of Physicians (ACP).

In 2022 – 2023 there were 30 active research protocol, 20 publications in national journals, and 15 national conference presentations.

Departmental QI projects:

• Acute exacerbation of COPD (eCOPD) – Multi-department QIP assessing inpatient COPD exacerbations, management, and outpatient follow up.
• Intrapleural Catheters (IPC) – Assessing the timing, education, and long-term outcomes of patients with intrapleural catheters.
• Pulmonary Embolism Response Team –  Multi-department quality improvement project optimizing the assessment, management, and long term follow up with patients suffering from acute pulmonary embolism.
• Extracorporeal Membrane Oxygenation (ECMO) working group – Currently assessing the timing of extubation while receiving extracorporeal support.

Each fellow is required to participate in a quality improvement (QI) project. Projects can be self-initiated or as part of a department level program.

Academic Development

• As BAMC is a core site for Uniformed Services University Medical students, fellows can apply for the academic position of Teaching fellow. Upon graduation from fellowship, junior staff may apply for Assistant Professor and can work their way toward Associate Professor and eventually toward full Professorship.
• Semi-annual faculty development courses are available to fellows and staff through Uniformed Services University

Professional Development

As part of our weekly academics, we hold quarterly professional development sessions. Examples of sessions include:

• How to write a performance report
• Navigating a military and clinical career
• How to give and receive feedback
• How to teach procedures

Additionally, several military specific professional development courses are available to trainees during fellowship to include Captain’s Career Course, Air Command and Staff College, and Critical Care Air Transport Initial.

• Brooke Army Medical Center, San Antonio, Texas
• Wilford Hall Ambulatory Surgical Center, San Antonio, Texas
• University of Texas Hospital, San Antonio, Texas
• University of Texas M.D. Anderson Cancer Center, Houston, Texas
• Baptist Medical Center Medical Intensive Care Unit, San Antonio, Texas
• Texas Center for Infectious Disease, San Antonio, Texas

Medical Students

Medical students can rotate though the MICU, Inpatient consults service, and outpatient clinics as part of their sub-I rotations or as part of their core curriculum blocks. Medical students are given a comprehensive experience with patient encounters, bedside education, participating in our academic sessions, and informal didactics from one of our twelve academic faculty. Medical students are encouraged to participate in patient care and are often given opportunities to learn advanced pulmonary procedures to include bronchoscopy, chest tubes, vascular access, and thoracentesis. To schedule a rotation, contact usarmy.jbsa.medcom-bamc.mbx.saushec-clerkship@health.mil.

Residents

Residents rotate through the medical ICU as part of their core rotations and can rotate through the inpatient and outpatient service as an elective. On the inpatient service, residents assist with the busy inpatient service and often perform pulmonary specific procedures to include thoracentesis, chest tube, intrapleural catheters, and bronchoscopy. Residents are considered an integral part of the inpatient service and are exposed to a wide variety of pulmonary diseases, procedures, and education. On the outpatient side, residents perform the initial evaluation of new consults under the guidance of a fellow and faculty.

Pulmonary and Critical Care medicine is the tip of the spear for internal medicine. It requires someone who is quick on their feet, able to remain calm during stressful situations, and maintain a high level of attention to detail. A career in PCCM is demanding, yet incredibly rewarding. We balance the demands of our job by being a close knit and fun program. We enjoy hanging out outside of work, faculty doors are always open, and you’re viewed as a junior colleague. We understand that life gets in the way sometimes and we take pride in being able to cover down for one another.

Interested applicants should contact the program to schedule an in-person or virtual interview. The benefit of in-person interviews allows the applicant to spend a full day with the fellowship, participate in our educational program, meet with staff and fellows, and participate in a formal interview. For applicants who interview virtually, separate from the formal virtual interview we arrange a virtual meet-and-greet with current fellows as a forum for asking additional questions about our learning environment and culture of the program.

If you would like to schedule an interview with our program, please contact dha.jbsa.brooke-amc.list.saushec-pulmccm@health.mil.

Program graduates take the American Board of Internal Medicine - Pulmonary Disease and Critical Care Medicine board exam(s). This exam is offered annually. To become fully board certified, applicants are eligible to take board certification exam 4 months following graduation. To be eligible to take specialty board exams, graduates must complete all pre-requisites required by June.

BAMC is a core clerkship stie for the USUHS and, as such, have 3rd year medical students rotating with us on their core MICU or Pulmonary clerkship. Fellows are their primary educators. In addition, throughout June – October we have several 4th year medical students rotating for audition rotations. Internal Medicine interns and residents rotate through our department.

As part of mastering PCCM, fellows are given many different teaching opportunities to include:

• Medical student didactic lectures
• Medicine and Surgery resident lectures
• Journal club
• Morbidity and Mortality Conference
• Academic lectures
• Grand rounds
• Hospital wide education: Code Blue training, Individual Critical Task List (ICTL) skills validation

All the faculty are subspecialist-trained, which allows direct mentorship to our fellows.

Subspecialties include: Internal Medicine, Pulmonary Disease, Critical Care Medicine, Sleep Medicine, and Interventional Pulmonology.

• Advanced Airway Course
• Bronchoscopy
• Critical Skills in Expeditionary Medicine
• Extracorporeal Membrane Oxygenation (ECMO) Course
• Critical Care Ultrasound Course

• Each class has an assigned faculty mentor that meets with them quarterly for check in and provide mentorship.
• Incoming fellows have a mentor assigned for their first year. During their 2nd and 3rd year, fellows select their mentor from our service.
• Mentors and mentees meet quarterly following a guide about topics to cover focusing on research, militate and career goals.

Our program has proactively integrated a curricular/extracurricular wellness curriculum. Regularized social interactions has become the foundation of the social piece of this curriculum as well as lectures on wellness and resiliency (led by faculty and program leadership). Additionally, we have formalized the previously “informal check-in’s” with the fellows, both in group settings [twice monthly before academics] and individually).