Use of a high-flow oxygen delivery system in a critically ill patient with dementia.

We used a high-flow nasal cannula with a patient who required a high fraction of inspired oxygen but could not tolerate a nasal or facial mask. We saw a 92-year-old woman with delirium and dementia in the intensive care unit for multi-lobar pneumonia with severe hypoxemia. Attempts to oxygenate the patient failed because she was unable to tolerate various facial and nasal masks. We then tried a high-flow nasal cannula (Vapotherm 2000i), which she tolerated well, and she had marked improvement in gas exchange and quality of life. The patient had severe health-care-associated pneumonia, accompanied by delirium and hypoxemia. It became apparent that the patient's death was imminent, and the goal of therapy was palliative. She had previously clearly expressed a desire not to undergo intubation and mechanical ventilation. In a situation where the patient was agitated and unable to tolerate a mask, the high-flow cannula reduced her agitation and improved her dyspnea, oxygenation, tolerance of oxygen therapy, and comfort at the end of life. Oxygen via high-flow cannula may enhance quality of life by reducing hypoxemia in patients who are unable to tolerate a mask but need a high oxygen concentration.

Ethics training for military medical trainees: the Brooke Army Medical Center experience.

Biomedical ethics training during graduate medical education programs is required by the Accreditation Council for Graduate Medical Education. Apart from this requirement, medical ethics education is an integral component of military medical practice. Although ethics education and training are required, tools to assess the effectiveness of ethics education are not well developed. Furthermore, although biomedical ethics education is mandated for new Army physician trainees, there has not been a systematic objective assessment of the effectiveness of that training. We report the concept underlying the design and implementation of a military biomedical ethics seminar for new Army physician trainees. Combining a didactic component and case analysis through small-group discussions, we emphasized providing tools to analyze ethical dilemmas both in the medical center environment and in the operational medicine environment. A total of 47 Army interns participated in the seminar. Eighty-nine percent of participants agreed or strongly agreed that the ethics orientation met expectations. Seventy-two percent agreed or strongly agreed that the information presented would affect their practice. Ninety-six percent thought that the small-group discussions were effective, and 80% thought that the presentations enhanced knowledge from medical school.

Diffuse bronchiectasis as the primary manifestation of endobronchial sarcoidosis.

Sarcoidosis is an idiopathic disease that most commonly involves the lungs and is characterized by granulomatous inflammation. Bronchiectasis is one pulmonary manifestation of sarcoidosis, although it is almost always observed as traction bronchiectasis in the setting of fibrotic lung disease. A 50-year-old woman was evaluated for chronic cough and bronchiectasis with a small amount of peripheral upper lobe honeycombing and no significant pulmonary fibrosis or lymphadenopathy. After an extensive laboratory and imaging evaluation did not identify a cause of her bronchiectasis, bronchoscopy was performed to assess for primary ciliary dyskinesia and revealed a diffuse cobblestone appearance of the airway mucosa. Endobronchial biopsies and lymphocyte subset analysis of bronchoalveolar lavage fluid were consistent with a diagnosis of sarcoidosis. We believe endobronchial sarcoidosis should be included in the differential diagnosis of patients presenting with bronchiectasis.

Advance directives and do-not-resuscitate orders on general medical wards versus the intensive care unit.

The records of 335 patients admitted to the general medicine wards and to the medical intensive and coronary care unit (MICCU) at Brooke Army Medical Center were retrospectively reviewed to assess the frequency of advance directives and "do not resuscitate" (DNR) designations. Two hundred sixty-seven (79.7%) were admitted to the ward and 68 (20.3%) were admitted to the MICCU. Advance directives were executed in 14.9% of patients. DNR designations were made for 21 (7.9%) patients on the ward and 11 (16.2%) patients in the MICCU (p = 0.064). There were no statistical differences in mean length of stay, presence of advance directives, or documentation of advance directives in ward versus MICCU patients. However, there was a statistical difference in the number of deaths in the MICCU as compared with that on the ward (9.7 vs. 2.7%, p < 0.05). The frequency of advance directives and DNR designations did not differ between ward and MICCU patients in this population, although there was a trend for greater DNR designations in the MICCU environment.