Konrad Davis

Safety of topical tetracaine in patients undergoing flexible bronchoscopy.

Lidocaine is currently the most commonly used topical anesthetic during flexible bronchoscopy (FFB) in North America. Tetracaine, a longer-acting agent, might produce better airway analgesia; however, previous literature has suggested that tetracaine is more risky and can even result in cardiac arrest. The maximum recommended tetracaine dose for topical anesthesia is 20 mg. Over the past 30 years, our Pulmonary Special Procedures Unit has used topical tetracaine in considerably higher doses. In this study, we sought to review the safety of this approach. We completed a retrospective review of all FFBs performed on nonintubated patients by a single bronchoscopist from January 2005 to February 2007. The primary outcome variables included adverse reactions and tetracaine dose administered. Five hundred thirty-seven FFBs were performed on 431 patients. Patient age ranged from 20 to 94 years, with a mean age of 55 years. Eighty-one percent (n=434) of these FFBs were performed using only topical anesthesia. Tetracaine solution 0.45% was used in 99.6% of these procedures. Mean tetracaine dose was 120 mg (range: 18 to 158 mg). No adverse reactions attributable to tetracaine were noted. Specifically, no cardiac or neurologic events occurred. Bronchospasm was noted in 1.5% of patients and 1 patient required intubation after the procedure owing to severe hypoxemia. This retrospective study suggests that topical tetracaine at doses up to 8 times the “recommended” dose is safe for the use during FFB.

Pneumomediastinum complicating transbronchial needle aspiration.

Transbronchial needle aspiration (TBNA) is a safe procedure with a reported complication rate of less than 1%. Pneumomediastinum after TBNA has not been reported in the English literature in the past. We present the case of a 65-year-old woman with widely metastatic small cell carcinoma, who developed pneumomediastinum after flexible bronchoscopy with TBNA. A persistent visible defect in the bronchial wall at the site of the needle insertion strongly implicated the TBNA as the cause of the pneumomediastinum.

A tree grows in bronchus.

A tracheobronchial foreign body (TFB) can be a life-threatening emergency that requires urgent intervention. TFBs occur most commonly in childhood as a result of aspiration. Traumatic TFB is not frequently reported in the literature. All reported cases of traumatic TFB to date have involved a projectile mechanism of injury. We report a case of a patient who presented with recurrent pneumonia. Flexible bronchoscopy revealed a TFB partially obstructing the right bronchus intermedius. Pathology confirmed the TFB to consist of wood. Further history revealed that the patient experienced an impaling injury on a tree sucker more than 30 years before presentation. Surgery was required to remove the TFB. This case illustrates the importance of the patients history, and is the first reported case of an impaling injury causing a traumatic TFB.

Augmenting Clinical Performance in Combat Casualty Care: Telemedicine to Automation

Emerging efforts in information science offer the possibility for clinicians to better utilize computer technology to decrease cognitive load, enhance decision making, and, improve patient outcomes. Recent natural disasters and mass casualty events across the United States and abroad spotlight the challenges of delivering healthcare in austere contexts. Austerity is a situation defined by limited resources of some or all of the following: equipment, medicines, diagnostics, personnel, knowledge, training, skills, and expertise. It is in this context that the military is focusing efforts to develop new telemedical, autonomous, and robotic systems to support local caregivers. Military human-computer models that support telemedicine and autonomous care in austere environments may help shape similar civilian healthcare solutions in similarly austere contexts of remoteness, natural disaster, and mass casualty. This paper will discuss the clinical challenges and capability gaps of providing comprehensive medical support in this context and some of the tools the military is developing to address them.

Nutritional Support Using Enteral and Parenteral Methods

The purpose of this Clinical Practice Guideline is to provide an approach for optimal nutritional support in the postinjury period for those injured in combat. Indications and contraindications for enteral and parenteral nutrition are addressed. Timing of nutritional support, nutritional goals, energy requirements, and ideal formula selection for various types of traumatic injuries are addressed. Challenges encountered providing nutrional support for the traumatically injured in the deployed environment are also discussed.

The Initial Impact of Tele-Critical Care on the Surgical Services of a Community Military Hospital

Introduction Mortality is reduced in hospitals staffed with intensivists, however, many smaller military hospitals lack intensivist support. Naval Hospital Camp Pendleton (NHCP) is a Military Treatment Facility (MTF) that operates a 6-bed Intensive Care Unit (ICU) north of its referral center, Naval Medical Center San Diego (NMCSD). To address a gap in NHCP on-site intensivist coverage, a comprehensive Tele-Critical Care (TCC) support system was established between NHCP and NMCSD. To examine the initial impact of telemedicine on surgical ICU patients, we compare NHCP surgical ICU admissions before and after TCC implementation. Materials and methods Patient care by remote intensivist was achieved utilizing video teleconferencing technology, and remote access to electronic medical records. Standardization was promoted by adopting protocols and mandatory intensivist involvement in all ICU admissions. Surgical ICU admissions prior to TCC implementation (pre-TCC) were compared to those following TCC implementation (post-TCC). Results Of 828 ICU admissions, 21% were surgical. TCC provided coverage during 35% of the intervention period. Comparing pre-TCC and post-TCC periods, there was a significant increase in the percentage of surgical ICU admissions [15.3 % vs 24.6%, p = 0.01] and the average monthly APACHE II score [4.1vs 6.5, p = 0.03]. The total number of surgical admissions per month also increased [3.9 vs 6.3, p = 0.009]. No adverse outcomes were identified. Conclusion Implementation of TCC was associated with an increase in the scope and complexity of surgical admissions with no adverse outcomes. Surgeons were able to safely expand the surgical services offered requiring perioperative ICU care to patients who previously may have been transferred. Caring for these types of patients not only maintains the operational readiness of deployable caregivers but patient experience is also enhanced by minimizing transfers away from family. Further exploration of TCC on surgical case volume and complexity is warranted.

Critical Care in the Military Health System: A Survey-Based Summary of Critical Care Services

Introduction Critical care is an important component of in-patient and combat casualty care, and it is a major contributor to U.S. healthcare costs. Regular exposure to critically ill and injured patients may directly contribute to wartime skills retention for military caregivers. Data describing critical care services in the Military Health System (MHS), however, is lacking. This study was undertaken to describe MHS critical care services, their resource utilization, and differences in care practices amongst military treatment facilities (MTFs). Materials and Methods Twenty-six MTFs representing 38 adult critical care services or intensive care units (ICUs) were surveyed. The survey collected information about organizational structure, resourcing, and unit characteristics at the time of a concurrent 24-h point-prevalence survey designed to describe patient characteristics and staffing in these facilities. The survey was anonymous and protected health information was not collected. We analyzed the data according to high capacity centers (HCCs) (≥200 beds) and low capacity centers (LCCs) (<200 beds). Differences between HCCs and LCCs were compared using Fishers exact test. Results Seventeen MTFs (7 HCCs and 10 LCCs), representing 27 ICUs, responded to the survey. This was a 65% response rate for MTFs and a 71% response rate for services/ICUs. HCCs reported more closed vs. open ICUs; more dedicated critical care services (i.e., medical and surgical ICUs vs. mixed ICUs); fewer respiratory therapists available, but more with certification; more total nursing staff and more critical care certified nurses; the use of subjectively more effective protocols (10.5 vs. 6.7 protocols/unit or service); higher utilization of an ICU daily rounds checklist (65% vs. 0%); and less consistency of clinician type participation during multidisciplinary rounds. ICU leadership structure was similar among the institutions. The majority of respondents were unable to provide summary APACHE II scores, but HCCs were more likely to submit this information than LCCs. Most centers perform multidisciplinary rounds daily, but they are more likely to be run by a physician credentialed in critical care at HCCs (85% vs. 59%, p < 0.05). 67% of respondents reported mortality rates <5%. The two services that reported mortality rates greater than 10% were both LCCs. Conclusion This is the first comprehensive report about MHS critical care services. Despite notable variability in data reporting, an important finding itself, this study highlights notable differences in organizational structure and resourcing between HCCs and LCCs within the MHS. The clinical implication of these differences (i.e., impact on patient outcomes) of these differences require further study. Better understanding of MHS critical care services may improve enterprise decision-making about these services which could ultimately improve care of combat casualties.