The Bellevue Hospital Center is the flagship of New York’s municipal hospital system. Bellevue is a lineal descendant of the infirmary for soldiers and slaves established in New Amsterdam by Jacob Vanenvanger in 1658. Bellevue Hospital has more than 30,000 admissions and more than 270,000 outpatient visits annually in a modern 21-floor facility constructed in 1974. In 1968, New York University assumed complete responsibility for the hospital’s teaching programs. The Chest Service is an independent service with a separate New York University Affiliation contract, and has a seat on the Bellevue Hospital Medical Board.
The Bellevue Pulmonary Consult Service provides an intense and high level period of clinical training. A first and second year fellow work as a team to provide consultation on requests from all clinical services, including Medicine, General Surgery, Surgical subspecialties, OB-GYN, Neurology, Psychiatry, and Pediatrics. The fellow evaluates the patient, presents his or her findings to the Attending, and provides a detailed consultation note in the patient’s chart. The second year fellow provides leadership and supervision, particularly on procedures.
Flexible bronchoscopes with associated techniques including transbronchial and endobronchial biopsy, brushings, bronchoalveolar lavage and tranbronchial node aspirates (TBNA) are taught on this service. An interventional bronchoscopy program introduces fellows to electrocautery, cryotherapy, argonplasma, lasertherapy and stent placement and rigid bronchoscopy. In addition fellows become technically skilled in closed pleural biopsy, insertion and management of small bore thoracostomy tubes and transthoracic needle biopsy of the lung.
The Consult Service sees a wide variety of acute and chronic chest disease, including an extraordinary number and variety of opportunistic infections accompanying HIV infection.
The historic Bellevue Chest Service is a unique training asset of our program. The Chest Service operates a 32-bed inpatient service. Practically all manifestations of acute chest disease are seen on this Service including tuberculosis, asthma, chronic obstructive lung disease, pulmonary complications of HIV infection, lung cancer, interstitial lung disease, pleural effusions, pneumothorax, sleep disordered breathing, thromboembolic diseases, sarcoidosis just to name a few.
Each second year fellow serves for two months as “Chest Chief ” for the Chest Service wards.
Direct patient care on the Chest Service is the responsibility of two PGY-2 residents and a physician assistant who rotate on this assignment The differential diagnosis and potential participation of patients in clinical research protocols are discussed. The chest chief reviews every admission, makes rounds with each resident team, and provides advice and instruction regarding patient care and performs all pulmonary procedures.
The Bellevue MICU is an active unit with a broad mix of patients, most with multiple system disorders. It is under the direction of Dr. Laura Evans. Approximately 60% of patients require mechanical ventilation, 25% have acute gastrointestinal emergencies, 25% have renal-metabolic disease with the remaining comprising neurological, hematological, and other disorders.
A first year pulmonary/critical care fellow reviews each of 12 cases daily with the assigned medical housestaff consisting of 4 interns and 3 residents and takes on a supervisory role comparable to that of a chief resident on the medical service. Senior medical residents and fellows from other subspecialty services also review selected cases, depending upon the nature of the illness. Nonetheless, the pulmonary fellow has overall supervisory responsibility, and conducts rounds in the ICU with attendings, housestaff, and other subspecialty fellows and staff. A second year pulmonary/critical care fellow serves as a second fellow in the Bellevue ICU. This fellow is responsible for critical care consults in the EW and all other critical care units (CCU, SICU, NSICU, etc.).
There are weekly didactic and patient management conferences covering the wide spectrum of critical care medicine. The fellows are responsible for organizing these conferences. There is also a monthly acid-base conference attended by the Renal and Pulmonary staffs in which the Critical Care fellow presents a patient with a difficult acid-base abnormality for analysis and discussion by the group. A state-of-the-art hemodynamic and ventilatory monitoring and data management system is in place in all of the special care units. The information and data evaluation is supervised by Dr. Roberta Goldring, Dr. Ken Berger and the staff of the Pulmonary Function Laboratory, and provides the basis of a weekly physiology conference.
A second year fellow performs as critical care consultant in Bellevue Hospital and works with the first year MICU fellow. Under the supervision of a monthly critical care attending, the critical care consult oversees the patients in the Emergency Ward (a multidisciplinary ICU) and provides individual consultation as needed in the other intensive care units (SICU, PICU, CCU).
The trainee receives instructions and experience with equipment and techniques for all of the clinical pulmonary function tests performed, principally by technicians, in this laboratory. The fellow reviews the patient’s clinical chart, and reviews and analyzes the PFT data. Dr. Goldring, Director of the Laboratory, Dr. Rapoport, Associate Director, or Dr. Kenneth Berger review selected cases with the trainee in two formal case review conferences each week. The fellow provides the final interpretation of the PFT data, and uses this experience to acquire advanced training in pulmonary physiology.
The fellow assists in the evaluation of patients referred to the NYU Sleep Disorders Center for the full range of sleep disorders. He/she participates in the initial clinical intake of new referrals, daily review of sleep studies, and evaluation of inpatients with respiratory failure referred for consultation. In addition to exposure to standard laboratory polysomnography, there is focus on special monitoring in and out of the sleep lab to assist in the evaluation of respiration. This includes diagnostic monitoring for apnea and periodic breathing, oxygen desaturation, and trend monitoring of assisted nocturnal ventilation.
Fellows also attend two weekly conferences held to review clinical patient data and selected topics in sleep medicine. Finally, the fellow assists in the analysis of data and trials of therapy with CPAP and nocturnal ventilation performed on inpatients. Supervision is provided by Drs. David Rapoport, Kenneth Berger, Indu Ayappa, Dennis Hwang, Marta Maczaj, Joyce Walsleben, and Omar Burschtin.
Outpatient management of lung diseases is taught at both Bellevue Hospital and the VA Hospital. Outpatient services at Bellevue Hospital include a two year rotation in the Chest Clinic which includes, management of tuberculosis, interstitial lung diseases, lung cancer, under the supervision of Drs. Condos and Rogers.
A rotation in the Bellevue Hospital Asthma Clinic in the third year of the fellowship provides an integrated approach to chronic airway disease management under the supervision of Drs. Reibman and Rogers. Optional rotations include those in the Occupational Medicine clinic and the community based Bellevue Hospital WTC Health Impacts Treatment Program.
First year fellows participate in the outpatient clinic at the VA Hospital in both the consultative chest clinic and outpatient sleep clinic.