Imaging in the Intensive Care Unit.

Radiology plays an important role in the management of the most seriously ill patients in the hospital. Over the years, continued advances in imaging technology have contributed to an improvement in patient care. However, even with such advances, the portable chest radiograph (CXR) remains one of the most commonly requested radiographic examinations. While they provide valuable information, CXRs remain relatively insensitive at revealing abnormalities and are often nonspecific. Chest computed tomography (CT) can display findings that are occult on CXR and is particularly useful at identifying and characterizing pleural effusions, detecting barotrauma including small pneumothoraces, distinguishing pneumonia from atelectasis, and revealing unsuspected or additional abnormalities which could result in increased morbidity and mortality if left untreated. CT pulmonary angiography is the modality of choice in the evaluation of pulmonary emboli which can complicate the hospital course of the ICU patient. This article will provide guidance for interpretation of CXR and thoracic CT images, discuss some of the invasive devices routinely used, and review the radiologic manifestations of common pathologic disease states encountered in ICU patients. In addition, imaging findings and complications of more specific clinical scenarios in which the incidence has increased in the ICU setting, such as patients who are immunocompromised, have interstitial lung disease, or COVID-19, will also be discussed. Communication between the radiologist and intensivist, particularly on complicated cases, is important to help increase diagnostic accuracy and leads to an improvement in the management of the most critically ill patients.

Reflections on New Evidence on Crisis Standards of Care in the COVID-19 Pandemic.

Crisis standards of care have been widely developed by healthcare systems and states in the United States during the COVID-19 pandemic, and in some rare cases have actually been used to allocate medical resources. All publicly available U.S. crisis standards of care with a mechanism for allocating scarce resources make use of the Sequential Organ Failure Assessment (SOFA) score in hopes of assigning scarce resources to those patients who are more likely to survive. We reflect on the growing body of evidence suggesting that the SOFA score has limited accuracy in predicting mortality among patients hospitalized with COVID-19 and that the SOFA score systematically disfavors Black patients. Use of the SOFA score for allocating scarce resources may therefore result in Black patients with equal likelihood of survival being deprived of life-saving medical resources. There is also a risk of injustice for patients with non-COVID-19 diagnoses, for whom the SOFA score may be a more accurate prognostic score, but who might nevertheless be unfairly (de)prioritized when assessed alongside COVID-19 patients using the same scoring system. For these reasons we recommend that the SOFA score not be used for triage purposes during the COVID pandemic, and that a national effort be made to develop and empirically test crisis standards of care in advance of the next public health emergency.

Challenges in interpreting cytokine data in COVID-19 affect patient care and management.

Challenges in using cytokine data are limiting Coronavirus Disease 2019 (COVID-19) patient management and comparison among different disease contexts. We suggest mitigation strategies to improve the accuracy of cytokine data, as we learn from experience gained during the COVID-19 pandemic.

Malignant hyperthermia in severe COVID-19: 2 case reports.

Malignant hyperthermia is a rare but potentially fatal condition. We present 2 cases of young patients with coronavirus disease 2019 (COVID-19) requiring intubation for hypoxic respiratory failure who both developed significant hyperthermia post intubation and were suspected to have malignant hyperthermia. However, the 2 patients had different responses to conservative management and dantrolene. These cases highlight the increased challenge imposed by intubation complications when managing patients with COVID-19.

Developing a Triage Protocol for the COVID-19 Pandemic: Allocating Scarce Medical Resources in a Public Health Emergency.

The coronavirus disease-2019 (COVID-19) has caused shortages of life-sustaining medical resources, and future waves of the virus may cause further scarcity. The Yale New Haven Health System developed a triage protocol to allocate scarce medical resources during the COVID-19 pandemic, with the primary goal of saving the most lives possible, and a secondary goal of making triage assessments and decisions consistent, transparent, and fair. We outline the process of developing the triage protocol, summarize the protocol itself, and discuss the major ethical challenges encountered, along with our answers to these challenges. These challenges include (1) the role of age and chronic comorbidities; (2) evaluating children and pregnant patients; (3) racial, ethnic, and socioeconomic disparities in health; (4) prioritization of healthcare workers; and (5) balancing clinical judgment versus protocolized assessments. We conclude with a review of the limitations of our protocol and the lessons learned. We hope that a robust public discussion of such protocols and the ethical challenges that they raise will result in the fairest possible processes, less need for triage, and more lives saved during future waves of the COVID-19 pandemic and similar public health emergencies.

Making Medical Treatment Decisions for Unrepresented Patients in the ICU. An Official American Thoracic Society/American Geriatrics Society Policy Statement.

Background and Rationale: ICU clinicians regularly care for patients who lack capacity, an applicable advance directive, and an available surrogate decision-maker. Although there is no consensus on terminology, we refer to these patients as "unrepresented." There is considerable controversy about how to make treatment decisions for these patients, and there is significant variability in both law and clinical practice.Purpose and Objectives: This multisociety statement provides clinicians and hospital administrators with recommendations for decision-making on behalf of unrepresented patients in the critical care setting.Methods: An interprofessional, multidisciplinary expert committee developed this policy statement by using an iterative consensus process with a diverse working group representing critical care medicine, palliative care, pediatric medicine, nursing, social work, gerontology, geriatrics, patient advocacy, bioethics, philosophy, elder law, and health law.Main Results: The committee designed its policy recommendations to promote five ethical goals: 1) to protect highly vulnerable patients, 2) to demonstrate respect for persons, 3) to provide appropriate medical care, 4) to safeguard against unacceptable discrimination, and 5) to avoid undue influence of competing obligations and conflicting interests. These recommendations also are intended to strike an appropriate balance between excessive and insufficient procedural safeguards. The committee makes the following recommendations: 1) institutions should offer advance care planning to prevent patients at high risk for becoming unrepresented from meeting this definition; 2) institutions should implement strategies to determine whether seemingly unrepresented patients are actually unrepresented, including careful capacity assessments and diligent searches for potential surrogates; 3) institutions should manage decision-making for unrepresented patients using input from a diverse interprofessional, multidisciplinary committee rather than ad hoc by treating clinicians; 4) institutions should use all available information on the patient's preferences and values to guide treatment decisions; 5) institutions should manage decision-making for unrepresented patients using a fair process that comports with procedural due process; 6) institutions should employ this fair process even when state law authorizes procedures with less oversight.Conclusions: This multisociety statement provides guidance for clinicians and hospital administrators on medical decision-making for unrepresented patients in the critical care setting.

A novel approach to the program evaluation committee.

BACKGROUND: The Accreditation Council for Graduate Medical Education requires each residency program to have a Program Evaluation Committee (PEC) but does not specify how the PEC should be designed. We sought to develop a PEC that promotes resident leadership and provides actionable feedback. METHODS: Participants were residents and faculty in the Traditional Internal Medicine residency program at Yale School of Medicine (YSM). One resident and one faculty member facilitated a 1-h structured group discussion to obtain resident feedback on each rotation. PEC co-facilitators summarized the feedback in written form, then met with faculty Firm Chiefs overseeing each rotation and with residency program leadership to discuss feedback and generate action plans. This PEC process was implemented in all inpatient and outpatient rotations over a 4-year period. Upon conclusion of the second and fourth years of the PEC initiative, surveys were sent to faculty Firm Chiefs to assess their perceptions regarding the utility of the PEC format in comparison to other, more traditional forms of programmatic feedback. PEC residents and faculty were also surveyed about their experiences as PEC participants. RESULTS: The PEC process identified many common themes across inpatient and ambulatory rotations. Positives included a high caliber of teaching by faculty, highly diverse and educational patient care experiences, and a strong emphasis on interdisciplinary care. Areas for improvement included educational curricula on various rotations, interactions between medical and non-medical services, technological issues, and workflow problems. In survey assessments, PEC members viewed the PEC process as a rewarding mentorship experience that provided residents with an opportunity to engage in quality improvement and improve facilitation skills. Firm chiefs were more likely to review and make rotation changes in response to PEC feedback than to traditional written resident evaluations but preferred to receive both forms of feedback rather than either alone CONCLUSIONS: The PEC process at YSM has transformed our program's approach to feedback delivery by engaging residents in the feedback process and providing them with mentored quality improvement and leadership experiences while generating actionable feedback for program-wide change. This has led to PEC groups evaluating additional aspects of residency education.

Evaluation of Swallow Function Post-Extubation: Is It Necessary to Wait 24 Hours?

BACKGROUND: Post-extubation dysphagia is associated with an increased incidence of nosocomial pneumonias, longer hospitalizations, and higher re-intubation rates. The purpose of this study was to determine if it is necessary to delay swallow evaluation for 24 hours post-extubation. METHODS: A prospective investigation of swallowing was conducted at 1, 4, and 24 hours post-extubation to determine if it is necessary to delay swallow evaluation following intubation. Participants were 202 adults from 5 different intensive care units (ICU). RESULTS: A total of 166 of 202 (82.2%) passed the Yale Swallow Protocol at 1 hour post-extubation, with an additional 11 (177/202; 87.6%) at 4 hours, and 8 more (185/202; 91.6%) at 24 hours. Only intubation duration ≥4 days was significantly associated with nonfunctional swallowing. CONCLUSIONS: We found it is not necessary to delay assessment of swallowing in individuals who are post-extubation. Specifically, the majority of patients in our study (82.2%) passed a swallow screening at 1 hour post-extubation.

Internal medicine trainees' knowledge and confidence in using the American Society of Hematology Choosing Wisely guidelines in hemostasis, thrombosis, and non-malignant hematology.

BACKGROUND: Several specialty societies participate in the Choosing Wisely (CW) campaign in an attempt to reduce waste in health care spending. We surveyed internal medicine (IM) residents with an objective of classifying knowledge of and confidence in using the American Society of Hematology (ASH) CW principles in hemostasis, thrombosis, and non-malignant hematology. METHODS: Multi-institutional study of IM residents at 5 academic training programs in the United States. A 10-question, case-based multiple choice test, with each question accompanied by a 5-point Likert-scale confidence assessment, was distributed electronically. Responses were summarized with frequencies and percentages or medians and ranges, as appropriate. Two sample t-tests or Wilcoxon rank-sum tests were used to compare confidence and knowledge scores. RESULTS: Of 892 IM residents, 174 (19.5%) responded to all questions. Overall, residents answered a median of 7 of 10 questions correctly (range 2-10) and median resident confidence in their responses was 3.1 (on a 5-point scale). Correct responses were significantly associated with higher confidence for all but one question. Having a hematology rotation experience was significantly associated with more correct responses and with higher confidence (p = 0.001 and p<0.001, respectively). CONCLUSIONS: IM residents at several academic hospitals have variable knowledge of ASH-CW guidelines in thrombosis and hemostasis/non-malignant hematology. Residents who have done hematology rotations, particularly a hematology consult rotation, were more likely to answer questions correctly and to be more confident that their answers were correct. Adequate clinical exposure and training in cost-effective care is essential to train clinicians who are cost-conscious in any specialty.

A Young Man With Hemoptysis and Cavitary Lung Lesions.

CASE PRESENTATION: A man in his 20s presented with 2 months of mild fatigue and intermittent hemoptysis of less than a tablespoon per episode. He was previously healthy and was on no medications. He denied fevers, night sweats, weight loss, wheezing, dyspnea, musculoskeletal symptoms, and rashes. He had emigrated from a South American country to the United States 3 years earlier. He worked as a groundskeeper but had no exposures to animals, mold, or dusts. He reported rare prior cigarette smoking with no history of alcohol or drug use. He was unsure whether he had received the Bacillus Calmette-Guérin vaccine.

Critical Care at the End of Life.

Intensive care unit (ICU) admission is common among patients approaching the end of their lives from acute as well as chronic life-limiting conditions. ICU providers are expected to have basic palliative care skills integrated into their routine practice. Palliative care skills can be applied to all ICU patients, regardless of prognosis, and may improve patient- and family-centered end of life (EOL) care in the ICU. Consultative palliative care models may be required for more complex palliative care needs including symptom management, medical decision making, and bereavement. This review discusses integrative and consultative palliative care models and the role of triggers for palliative care consultation, particularly when they are tailored to the needs of individual ICUs. We then review the evidence for providing several palliative care domains in the ICU and some of the ethical considerations surrounding EOL care in the ICU. Finally, we highlight the importance of self-care and peer support groups to mitigate the risk of burnout for clinicians providing EOL care in the ICU.