Paul L. Rogers

Nonspecific Interstitial Pneumonitis without Evidence of Pneumocystis carinii in Asymptomatic Patients Infected with Human Immunodeficiency Virus (HIV)

STUDY OBJECTIVE To assess how often Pneumocystis carinii organisms, P. carinii pneumonia, or other pulmonary pathologic processes were present in persons infected with human immunodeficiency virus (HIV) without pulmonary symptoms or previous history of P. carinii, and with a normal chest roentgenogram. DESIGN Serial, prospective assessment of eligible HIV-seropositive patients over 21 months. PATIENTS Twenty-four HIV-seropositive patients with either a nonpulmonary manifestation of the acquired immunodeficiency syndrome (AIDS) (n = 12) or an absolute CD4 lymphocyte count of 0.200 X 10(9) cells/L or less (n = 12), no pulmonary symptoms, a normal chest roentgenogram, no history of P. carinii pneumonia, and no history of treatment with antipneumocystis prophylaxis. INTERVENTIONS Pulmonary assessment with arterial blood gases, pulmonary function tests, gallium-67 citrate scans, and bronchoscopy with bronchoalveolar lavage and transbronchial biopsies. MEASUREMENTS AND MAIN RESULTS Mean alveolar-arterial gradient was 11.1 mm Hg +/- 8.5 and mean diffusion capacity was 73.0% +/- 20.0% of predicted. None of the 24 patients showed P. carinii or other pathogens on stains of bronchoalveolar lavage fluid. No patient had histologic evidence of P. carinii pneumonia. Transbronchial biopsy specimens showed chronic, nonspecific interstitial pneumonitis (11 of 23) and no pathologic abnormality (12 of 23). Six patients have developed P. carinii pneumonia during 2 to 18 months of follow-up. CONCLUSIONS HIV-infected patients without pulmonary symptoms did not have detectable Pneumocystis organisms in bronchoalveolar lavage fluid or transbronchial biopsy specimens; but 11 of 23 had evidence of chronic, nonspecific interstitial pneumonitis. Pneumocystis organisms in a pulmonary specimen from a symptomatic patient probably indicate the cause of the pulmonary dysfunction even if only a few are detected.

Quantifying learning in medical students during a critical care medicine elective : A comparison of three evaluation instruments

Objective To compare three different evaluative instruments and determine which is able to measure different aspects of medical student learning. Design Student learning was evaluated by using written examinations, objective structured clinical examination, and patient simulator that used two clinical scenarios before and after a structured critical care elective, by using a crossover design. Participation Twenty-four 4th-yr students enrolled in the critical care medicine elective. Interventions All students took a multiple-choice written examination; evaluated a live simulated critically ill patient, requested data from a nurse, and intervened as appropriate at different stations (objective structured clinical examination); and evaluated the computer-controlled patient simulator and intervened as appropriate. Measurements and Main Results Students’ knowledge was assessed by using a multiple-choice examination containing the same data incorporated into the other examinations. Student performance on the objective structured clinical examination was evaluated at five stations. Both objective structured clinical examination and simulator tests were videotaped for subsequent scores of responses, quality of responses, and response time. The videotapes were reviewed for specific behaviors by faculty masked to time of examination. Students were expected to perform the following: a) assess airway, breathing, and circulation; b) prepare a mannequin for intubation; c) provide appropriate ventilator settings; d) manage hypotension; and e) request, interpret, and provide appropriate intervention for pulmonary artery catheter data. Students were expected to perform identical behaviors during the simulator examination; however, the entire examination was performed on the whole-body computer-controlled mannequin. The primary outcome measure was the difference in examination scores before and after the rotation. The mean preelective scores were 77 ± 16%, 47 ± 15%, and 41 ± 14% for the written examination, objective structured clinical examination, and simulator, respectively, compared with 89 ± 11%, 76 ± 12%, and 62 ± 15% after the elective (p < .0001). Prerotation scores for the written examination were significantly higher than the objective structured clinical examination or the simulator; postrotation scores were highest for the written examination and lowest for the simulator. Conclusion Written examinations measure acquisition of knowledge but fail to predict if students can apply knowledge to problem solving, whereas both the objective structured clinical examination and the computer-controlled patient simulator can be used as effective performance evaluation tools.

Admission of AIDS patients to a medical intensive care unit: causes and outcome.

As the number of cases of AIDS increases, it is important to determine whether ICUs can be productively and safely used for this patient population. From July 1981 to March 1987, 216 patients were admitted to the medical ICU: 166 (77%) were admitted for procedures and 50 (23%) were admitted for life-sustaining support. Most of the patients were admitted for respiratory failure (36 of 50), primarily as a result of Pneumocystis carinii pneumonia. Other patients were admitted for cardiovascular instability (six of 50 patients), CNS dysfunction (four patients), or other reasons (four patients). Of 50 patients admitted to the ICU, 13 (26%) were alive 3 months after hospital discharge. Despite 25 needle-stick injuries and 56 mucosal splashes involving human immunodeficiency virus (HIV)-infected patients and staff, no staff member converted HIV serology. These results suggest that AIDS patients may benefit from ICU admission. These patients appear to pose a low risk to the hospital staff in terms of occupationally acquired HIV infection, but strong emphasis needs to be placed on minimizing accidental exposures to potentially infected body fluids and to adhering to universal precautions.

Multisociety task force recommendations of competencies in Pulmonary and Critical Care Medicine.

RATIONALE Numerous accrediting organizations are calling for competency-based medical education that would help define specific specialties and serve as a foundation for ongoing assessment throughout a practitioners career. Pulmonary Medicine and Critical Care Medicine are two distinct subspecialties, yet many individual physicians have expertise in both because of overlapping content. Establishing specific competencies for these subspecialties identifies educational goals for trainees and guides practitioners through their lifelong learning. OBJECTIVES To define specific competencies for graduates of fellowships in Pulmonary Medicine and Internal Medicine-based Critical Care. METHODS A Task Force composed of representatives from key stakeholder societies convened to identify and define specific competencies for both disciplines. Beginning with a detailed list of existing competencies from diverse sources, the Task Force categorized each item into one of six core competency headings. Each individual item was reviewed by committee members individually, in group meetings, and conference calls. Nominal group methods were used for most items to retain the views and opinions of the minority perspective. Controversial items underwent additional whole group discussions with iterative modified-Delphi techniques. Consensus was ultimately determined by a simple majority vote. MEASUREMENTS AND MAIN RESULTS The Task Force identified and defined 327 specific competencies for Internal Medicine-based Critical Care and 276 for Pulmonary Medicine, each with a designation as either: (1) relevant, but competency is not essential or (2) competency essential to the specialty. CONCLUSIONS Specific competencies in Pulmonary and Critical Care Medicine can be identified and defined using a multisociety collaborative approach. These recommendations serve as a starting point and set the stage for future modification to facilitate maximum quality of care as the specialties evolve.

What is taught, what is tested: Findings and competency-based recommendations of the Undergraduate Medical Education Committee of the Society of Critical Care Medicine

Introduction:Addressing an unexpected shortfall of intensivists requires early identification and training of appropriate personnel. The purpose of this study was to determine how U.S. medical students are currently educated and tested on acute care health principles. Hypothesis/Methods:A survey of critical care education with telephone follow-up was mailed to the deans of all 126 medical schools. Web site review of medical school curricula for critical care education was performed. Upon invited request, four members of the Undergraduate Medical Education Committee (UGMEC) reviewed 1,200 pool questions of step II of the U.S. Medical Licensing Examination (USMLE) given to graduating medical students for critical care content. Descriptive statistics are employed. Results:Survey response rate was 49% and 88% by the second mailing with Web site review. Forty-five percent of U.S. medical schools responding had formal undergraduate critical care didactic curricula averaging 12 ± 3 hrs: 60% were elective, 60% taught in the 4th year. Eighty percent of clinical ICU rotations offered were elective. Sixty percent of schools taught 11 key critical care procedures in the 3rd or 4th year; 17% required them to graduate. Nineteen percent of Step II USMLE questions had critical care content; 58% dealt with pulmonary or cardiac disease. Conclusions:Graduating medical students are tested (and licensed accordingly) on critical care knowledge, despite an inconsistent exposure to the discipline in medical school. The UGMEC has drafted competency-based recommendations for acute health care delivery that encourage mandatory didactic and procedural critical care training. The UGMEC recommends that critical care rotations with didactic curricula be required for undergraduate education and that acute care procedural skills be an important component of these curricula.

Trial of shift scheduling with standardized sign-out to improve continuity of care in intensive care units.

Background:Since 2003, the Accreditation Council for Graduate Medical Education requires residency programs to restrict to 80 hrs/wk, averaged over 4 wks to improve patient safety. These restrictions force training programs with night call responsibilities to either maintain a traditional program with alternative night float schedules or adopt a “shift” model, both with increased handoffs. Objective:To assess whether a 65 hrs/wk shift-work schedule combined with structured sign-out curriculum is equivalent to a 65 hrs/wk traditional day coverage with night call schedule, as measured by multiple assessments. Design:Eight-month trial of shift-work schedule with structured sign-out curriculum (intervention) vs. traditional call schedule without curriculum (control) in alternating 1–2 month periods. Setting:A mixed medical–surgical intensive care unit at a tertiary care academic center. Subjects:Primary subjects: 19 fellows in a Multidisciplinary Critical Care Training Program; Secondary subjects: intensive care unit nurses and attending physicians, families of intensive care unit patients. Interventions:Implementation of shift-work schedule, combined with structured sign-out curriculum. Measurements:Workplace perception assessment through Continuity of Care Survey evaluation by faculty, fellows, and nurses through structured surveys; family assessment by the Critical Care Family Needs Index survey; clinical assessment through intensive care unit mortality, intensive care unit length of stay, and intensive care unit readmission within 48 hrs; and educational impact assessment by rate of fellow didactic lecture attendance. Main Results:There were no statistically significant differences in surveyed perceptions of continuity of care, intensive care unit mortality (8.5% vs. 6.0%, p = .20), lecture attendance (43% vs. 42%), or family satisfaction (Critical Care Family Needs Index score 24 vs. 22) between control and intervention periods. There was a significant decrease in intensive care unit length of stay (8.4 vs. 5.7 days, p = .04) with the shift model. Readmissions within 48 hrs were not different (3.6% vs. 4.9%, p = .39). Nurses preferred the intervention period (7% control vs. 73% intervention, n = 30, p = .00), and attending faculty preferred the intervention period and felt continuity of care was maintained (15% control vs. 54% intervention, n = 11, p = .15). Conclusions:A shift-work schedule with structured sign-out curriculum is a viable alternative to traditional work schedules for the intensive care unit in training programs.

Adult respiratory distress syndrome associated with epidural fentanyl infusion.

Objective: To determine the cause of unexplained postoperative adult respiratory distress syndrome (ARDS). Design: Case‐control study of postoperative ARDS. Setting: Intensive care unit (ICU) of a Veterans Affairs hospital. Patients: Six postoperative patients recovering from uncomplicated vascular or cardiothoracic surgery developed unexplained ARDS. Controls were 17 patients having similar procedures without the development of ARDS. Intervention: Infusion of fentanyl with a tamper‐proof device. Measurements and Main Results: Development of ARDS. ARDS began 1 to 4 days after surgery, was characterized by maximum alveolar‐arterial oxygen gradient that ranged from 232 to 544 torr (30.9 to 72.5 kPa), and was associated with death of two patients. We observed no association with patient location before ARDS onset, nonanalgesic medication administered, staff assignment, or mode of respiratory therapy. All six patients who developed unexplained ARDS had received epidural fentanyl compared with none of 17 control patients without ARDS ( p = .0002). We instituted a tamper‐proof mode of parenteral fentanyl administration, and subsequently observed one case of ARDS in 26 consecutive surgical patients ( p = .000014). Conclusions: Based on these findings, as well as a prior history of fentanyl theft at our institution, we conclude that tampering with fentanyl infusate was responsible for the ARDS epidemic that we observed. (Crit Care Med 1994; 22:1579–1583)

Severe Pneumocystis carinii pneumonia produces a hyperdynamic profile similar to bacterial pneumonia with sepsis.

Objectives: To investigate the effects of Pneumocystis carinii on the cardiovascular system. To compare the hemodynamic data from patients with P. carinii pneumonia with those data from patients with bacterial pneumonia with sepsis. Design: Retrospective, descriptive study of prospectively gathered hemodynamic and clinical data. Setting: Tertiary referral hospital, medical intensive care unit. Patients: Forty‐one consecutive patients with severe P. carinii pneumonia and 31 patients with bacterial pneumonia who had invasive hemodynamic monitoring for management of hypotension and/or hypoxemia. Measurements and Main Results: On initial presentation, both groups had a hyperdynamic hemodynamic profile that included tachycardia, an increased cardiac index, and a low systemic vascular resistance index. The mean heart rate of the P. carinii pneumonia patients (113 ± 3 beats/min) was significantly lower than that of the patients with bacterial pneumonia (126 ± 4 beats/min). The cardiac index, systemic vascular resistance index, pulmonary vascular resistance index, and pulmonary artery pressures did not differ significantly between the two groups. The patients with bacterial pneumonia had a significantly lower mean left ventricular stroke volume index and stroke work index than the patients with P. carinii pneumonia. Conclusion: P. carinii can produce a hyperdynamic hemodynamic profile similar to that seen in patients with bacterial pneumonia with sepsis. (Crit Care Med 1994; 22:50‐54)

Compensation for teaching in critical care

Objectives: To determine the financial or nonclinical time critical care program directors or teaching faculty members receive as compensation for their educational activities. To compare compensation types and amounts among critical care specialties and between university vs. nonuniversity sponsoring institutions. Data Sources and Extraction: Survey returns (46%) from critical care fellowship directors listed in the American Medical Association Graduate Medical Education Directory. Information was stratified according to fellowship specialty and type of sponsoring hospital and compared by chi‐square analysis and the Kruskal‐Wallis test. Conclusions: Most program directors (77%) and faculty (82%) receive no specified compensation for education‐related activities. Multidisciplinary programs are more likely to compensate faculty members than other specialty‐specific programs (p = .006). Most programs sponsored by university or military/federal hospitals do not provide specified compensation (79% and 100%, respectively). Overall, community hospital‐based programs provide a greater percentage of compensation to directors and faculty than university programs (for directors, p = .02; odds ratio, 3.85; for faculty, p = .001; odds ratio, 8.4). When compensation is specified, it is most often financial and it averages 18% of the salary (range, 5% to 100%) for directors and 19% of the salary for faculty (range, 5% to 50%). When reduced clinical time is provided (5% of program directors, 2% of faculty), it averages 13% (range, 8% to 18%) for directors and 18% (range, 10% to 25%) for faculty. Alternative methods for assigning educational compensation are discussed.