Kevin Felner

The Medical Emergency Team Call: A Sentinel Event That Triggers Goals of Care Discussion*

Objective:Several studies have questioned the effectiveness of rapid-response systems when measured by outcomes such as decreased overall hospital mortality or cardiac arrest rates. We studied an alternative outcome of rapid-response system implementation, namely, its effect on goals of care and designation of do not resuscitate. Design:Retrospective chart review. Setting:Veterans Administration Hospital in New York City. Subjects:All patients requiring a medical emergency team call. Interventions:None Measurements and Main Results:Monthly hospital census and discharge data, death occurrences, and do-not-resuscitate order placements were collected over an 8-year pre-medical emergency team and 5-year post-medical emergency team period. All medical emergency team calls and subsequent transfers to a critical care unit were reviewed and correlated to the placement and timing of do-not-resuscitate orders. Interrupted time-series analysis was used to evaluate the impact of the medical emergency team implementation on the change in trend of do-not-resuscitate orders and the hospital mortality. A total of 390 medical emergency team calls were associated with 109 do-not-resuscitate orders (28%). Of the 209 medical emergency team calls (54%) resulting in transfer to a critical care unit, 66 were associated with do-not-resuscitate orders, 73% of which were obtained after transfer. The odds of becoming do not resuscitate for a patient going to the ICU after the medical emergency team call were 2.9 (95% CI, 1.6–5.5; p = 0.001) times greater than for patients staying on the floors after the medical emergency team call. The medical emergency team implementation significantly changed the trend of do-not-resuscitate orders (p < 0.001) but had no impact on hospital mortality rate (p = 0.638). Conclusion:Implementation of a rapid-response system was associated with an increase in do-not-resuscitate order placement. As a sentinel event, medical emergency team activation and transfer to a critical care unit foster consideration of goals of care and frequently results in a transition to a palliative care strategy.

Malignant Mesothelioma Masquerading as a Multinodular Bronchioloalveolar Cell Adenocarcinoma With Widespread Pulmonary Nodules

A 72-year-old man had a unilateral pleural effusion and multiple bilateral pulmonary nodules. Thoracoscopic biopsy revealed multiple discrete nodules in the pleura and lung. The latter consisted of tall columnar malignant cells arranged on alveolar surfaces in a lepidic growth pattern. Mucin filled the alveolar lumina, both in the nodules and surrounding lung. It stained with Alcian blue but not with periodic acid Schiff, suggesting that it was a glycosaminoglycan, which was confirmed as hyaluronic acid by complete digestion with hyaluronidase. Tumor cells were calretinin, Wilms tumor-1, and high-molecular-weight cytokeratin 5/6 positive, and were negative for thyroid transcription factor-1, cytokeratin 7, and cytokeratin 20. Ultrastructurally, they had very long and abundant, slender microvilli typical of a malignant mesothelioma. This is the first example of a mesothelioma masquerading as a bronchioloalveolar carcinoma.

Goal-directed transthoracic echocardiography during advanced cardiac life support: A pilot study using simulation to assess ability

Introduction Goal-directed echocardiography (GDE) is used to answer specific clinical questions that provide invaluable information to physicians managing a hemodynamically unstable patient. We studied perception and ability of house staff previously trained in GDE to accurately diagnose common causes of cardiac arrest during simulated advanced cardiac life support (ACLS); we compared their results with those of expert echocardiographers. Methods Eleven pulmonary and critical care medicine fellows, 7 emergency medicine residents, and 5 cardiologists board certified in echocardiography were enrolled. Baseline ability to acquire 4 transthoracic echocardiography views was assessed, and participants were exposed to 6 simulated cardiac arrests and were asked to perform a GDE during ACLS. House staff performance was compared with the performance of 5 expert echocardiographers. Results Average baseline and scenario views by house staff were of good or excellent quality 89% and 83% of the time, respectively. Expert average baseline and scenario views were always of good or excellent quality. House staff and experts made the correct diagnosis in 68% and 77% of cases, respectively. On average, participants required 1.5 pulse checks to make the correct diagnosis. Of house staff, 94% perceived this study as an accurate assessment of ability. Conclusions In an ACLS-compliant manner, house staff are capable of diagnosing management-altering pathologies the majority of the time, and they reach similar diagnostic conclusions in the same amount of time as expert echocardiographers in a simulated cardiac arrest scenario.

Did Video Kill the Direct Laryngoscopy Star? Not Yet!

We read with interest “Difficult Airway Characteristics Associated with First Attempt Failure at Intubation Using Video Laryngoscopy in the Intensive Care Unit” (1). In that article, Joshi and colleagues assessed determinants of unsuccessful efforts by physicians in training to perform orotracheal intubation, using predominantly combined video and direct laryngoscopy devices (C-MAC; Karl Storz, Tuttlingen, Germany). After each intubation, the operators completed a data collection form, allowing the authors to analyze factors associated with failure of first-pass placement of an endotracheal tube. They identified several factors that contributed to first-pass failure; notably, blood in the airway, cervical immobility, airway edema, and obesity. The study by Joshi and coauthors adds to the existing literature in several ways, including the use of a nonanesthesia house staff intubating cohort, data on video-assisted intubations, trainee performance using combined video and direct laryngoscopy equipment, and the pinpointing of possible impediments to successful intubation. However, there are several items that require further clarification. First, the standard approach employed in this study when trainees used a device with both direct and indirect capabilities, such as the Storz C-MAC or GlideScope Direct Intubation Trainer (Verathon, Bothell, WA), is of clinical consequence. If glottis visualization was obscured, did the residents and fellows perform primarily direct laryngoscopy with a video “rescue,” or did they use primarily an indirect approach with a direct laryngoscopy rescue? The reason why blood in the airway caused failure is also of interest. Were these failures primarily a result of inability to visualize the larynx with the video device, or primarily a failure of an effort that combined direct and indirect laryngoscopy? In addition, it would be helpful to disclose details regarding bougie/introducer devices or laryngeal manipulation techniques in patients for whom a view was not possible using a video approach (assuming a nonhyperangulated blade was used). Second, the influence of the supervising physician is relevant, regarding the success of the procedures. Two recent investigations comparing success rates of direct-to-video laryngoscopy attempted by pulmonary and critical care fellows included immediate attending feedback and coaching (verbal communication) (2, 3). Information on the supervisory role of attending physicians is not included in the current report. Third, in their investigation of factors associated with failure to achieve first-pass successful intubation, Joshi and associates found that limited mouth opening was highly prevalent in both groups (24/166 of first-attempt failures, 64/740 in first-attempt success). However, an operational definition of limited mouth opening is not clearly stated in the report. In a multivariate risk index study of preoperative endotracheal intubation attempts by experienced anesthesiologists, mouth opening, defined as an interincisor tooth gap of ,4 cm, was found to have a positive predictive value for difficult intubation of 25% (4). In another study of difficult routine preoperative intubations, measured mouth opening (interincisor distance) was also strongly associated with easy vs. difficult intubation (5). Therefore, it would be of interest to know how limited mouth opening was defined and measured in the Joshi study. Finally, knowing the urgency of the endotracheal attempts is necessary to place the results of this investigation in an appropriate clinical context (1).