Başak Çoruh

Fentanyl-Induced Chest Wall Rigidity

Fentanyl and other opiates used in procedural sedation and analgesia are associated with several well-known complications. We report the case of a man who developed the uncommon complication of chest wall rigidity and ineffective spontaneous ventilation following the administration of fentanyl during an elective bronchoscopy. His ventilation was assisted and the condition was reversed with naloxone. Although this complication is better described in pediatric patients and with anesthetic doses, chest wall rigidity can occur with analgesic doses of fentanyl and related compounds. Management includes ventilatory support and reversal with either naloxone or a short-acting neuromuscular blocking agent. This reaction does not appear to be a contraindication to future use of fentanyl or related compounds. Chest wall rigidity causing respiratory compromise should be readily recognized and treated by bronchoscopists.

A Collaborative Critical Care Preceptorship for APRN Students

Advanced practice registered nurses (APRNs) increasingly are caring for critically ill patients as a part of interprofessional teams, but new APRNs may have limited critical care exposure in their training. We created a 12-week critical care preceptorship for APRN students as well as a curriculum composed of daily case-based teaching. Student assessment methods included direct observation, pretests and posttests of critical care knowledge, and presurveys and postsurveys of perceptions about critical care skills. The average score on the knowledge pretest was 50% and increased to 74% on the posttest (N = 10). Students reported increased comfort in several aspects of managing critically ill patients after the preceptorship. Descriptive feedback noted that the preceptorship is distinctive, comprehensive, and focused on student education. The evolving intensive care unit will have increasing numbers of APRNs, and a collaborative preceptorship can improve critical care know-ledge and perceptions of critical care skills in APRN students.

Family Support During Resuscitation: A Quality Improvement Initiative

&NA; Background Despite increasing support for family presence during cardiopulmonary resuscitation, a review of the literature revealed no published protocols or training curricula to guide hospitals in implementing a family support provider role. Objectives To develop a curriculum and train dedicated resuscitation team members whose role is to provide family support during in‐hospital resuscitation events. Methods An interdisciplinary team developed a 4‐hour training session for the family support staff. The session included an introduction to the evidence for family presence during resuscitation and local data on resuscitations. The training was composed of 4 sections: (1) clinical aspects of resuscitation, (2) integration into the resuscitation team and steps for providing family support during resuscitation, (3) responding to families in distress, and (4) self‐care practices. Before and after the training session, the participants completed surveys of self‐rated knowledge and attitudes toward family presence during resuscitation. Results Fifty‐nine social workers and 8 spiritual care providers were trained in 2015. There was a signifi cant increase in all rated aspects of knowledge of the family support role and self‐care strategies. Conclusion Through the creation of an interdisciplinary curriculum, an institution can effectively train health care providers in a new resuscitation team role: the family support provider. (Critical Care Nurse. 2017;37[6]:14‐23)

ICU Emergencies Simulation Curriculum for Critical Care Fellows: The Difficult Airway

Introduction Management of airway emergencies is a core skill for critical care fellows. There is no standardized training mechanism for difficult airway management among critical care fellowships, although fellows frequently cite management of airway catastrophes as an area of educational need. Methods Three simulation cases that are each approximately 15 minutes in length are presented. The cases represent airway emergencies encountered in the intensive care unit consisting of angioedema, endotracheal tube dislodgement, and endotracheal tube occlusion. Incorporated into the scenarios are planned incidents of interpersonal conflict requiring negotiation by the learner during a crisis event. The case descriptions are complete, with learning objectives and critical actions as well as all necessary personnel briefs and required equipment. Results The cases were completed over multiple simulation sessions on different days by 11 first-year critical care fellows during the 2016–2017 academic year. All participants demonstrated improvement in self-perceived confidence in airway management skills. Discussion The cases were felt to be realistic and beneficial and led to perceived improvement in management of airway emergencies and leadership during crisis scenarios.

Fellowship training in extracorporeal life support: Characterization and educational needs assessment

Purpose: Adult Extracorporeal Life Support (ECLS) use is rapidly increasing. The structure of fellowship ECLS education is unknown. We sought to define current ECLS education and identify curricular needs. Materials and methods: An anonymous survey with Likert, binary and free response questions was sent to Critical Care Program Directors (CCPDs). Results: A total of 103 CCPDs responded, a response rate of 31. ECLS training was provided by 64% (66/103) of fellowships. Importantly, 50% (52/103) of CCPDs agreed or strongly agreed that fellows should be competent in ECLS and 70% (72/103) agreed or strongly agreed that ECLS will be an important part of critical care in the next 10 years. Only 28% (29/103) and 37% (38/103) of CCPDs agreed or strongly agreed their fellows could independently manage veno‐arterial or veno‐venous ECLS, respectively. Formal ECLS education was 5 h or less in 85% (88/103) of programs. Desired curricular improvements were: simulation 50% (51/103), patient volume 47% (48/103), and didactics 44% (45/103). Conclusions: CCPDs identified ECLS as a critical care skill, but believe that a minority of fellows are prepared for independent practice. Simulation, formal didactics and clinical volume are key needs. These data will guide the development of ECLS curriculum. HIGHLIGHTSExtracorporeal Life Support (ECLS) competency is important for fellows to learn.There is significant variation in ECLS education across fellowships.ECLS curriculum development is needed, particularly simulation and didactics

Implementation of a Coaching Program for Peer Feedback on Large-Group Teaching

Teaching is an essential part of being an academic physician. Although teachers routinely receive learner evaluations, there are limited faculty development programs on teaching skills (1), and meaningful peer feedback is rare. Peer evaluation has been increasingly implemented in residency programs, resulting in changes in teaching behavior (2) and an increased awareness of peer feedback as a critical professional skill (3). Previous peer teaching assessment programs have resulted in faculty appreciation for the opportunity for structured discussion about their teaching and perception of an improvement in the quality of their teaching (4). Written peer feedback for faculty resulted in improved content and structure of talks, including items such as a statement of goals and a conclusion (5). University ofWashington Pulmonary and Critical CareMedicine (PCCM) faculty members deliver talks at a weekly core teaching conference attended by 20 to 30 PCCM fellows and faculty. Previously, PCCM faculty only received anonymous evaluations from peers for use in their teaching portfolios for promotion and tenure. These evaluations were primarily summative, with little constructive feedback for future teaching sessions. An in-person coaching system for PCCM faculty was implemented in 2011 to promote peer feedback and improve teaching skills in a large group setting.

ATS Core Curriculum 2016. Part IV. Adult Pulmonary Medicine Core Curriculum.

Gaëtane C. Michaud, Colleen L. Channick, Anica C. Law, Jessica B. McCannon, MaryEllen Antkowiak, Garth Garrison, David Sayah, Richard H. Huynh, Anna K. Brady, Rosemary Adamson, Hilary DuBrock, Praveen Akuthota, Chad Marion, Charles Dela Cruz, James A. Town, Başak Çoruh, and Carey C. Thomson Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, New York, New York; Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Pulmonary and Critical Care Medicine, University of Vermont College of Medicine, Burlington, Vermont; Pulmonary and Critical Care Medicine, University of California, Los Angeles, Los Angeles, California; Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington; Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut; and Pulmonary and Critical Care Medicine, Mount Auburn Hospital, Harvard Medical School, Boston, Massachusetts

Crowning achievement: a case of dental aspiration.

Aspiration of foreign bodies during dental procedures is a rare but potentially serious complication. We present a case of a 75-year-old man who aspirated a dental crown requiring flexible bronchoscopic retrieval. We discuss the risk factors for aspiration, the radiographic features of diagnosis, and the techniques for management and retrieval.

Shock in a Man with HIV Infection and a Large Mediastinal Mass

A middle-aged man with HIV infection presented because of progressive exertional dyspnea, orthopnea, pleuritic chest pain, and night sweats. He was found to have lymphoma encasing his heart and infiltrating the myocardium. Soon after admission, the patient developed shock and respiratory failure. Right heart catheterization was helpful in clarifying the pathophysiology of shock and suggested appropriate therapy.

Positive End-Expiratory Pressure. When More May Not Be Better

A 52-year-old woman was admitted to the intensive care unit with severe lobar pneumonia and septic shock. She remained hypoxemic despite intubation, a high fraction of inspired oxygen, and positive end-expiratory pressure (PEEP). When PEEP was increased further, she paradoxically became more hypoxemic and her blood pressure and central venous hemoglobin saturation fell. These problems resolved after an intervention that derived from an understanding of the physiological principles of PEEP.