Lightning rounds 41: Respiratory therapy with Keith Lamb

We explore the profession of respiratory therapy in the US, including their role and training and how to optimize our clinical relationships, with Keith Lamb (@kdlamb1), RRT, RRT-ACCS, FAARC, FCCM. Keith is an RT at the University of Virginia in Charlottesville, working clinically in neuro/surgical/trauma critical care, who has been active in research and has held a variety of leadership positions.

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Lightning rounds 40: Critical care medicine fellowships with Nicholas Ghionni

We chat about pulmonary/critical care medicine fellowship with recent graduate Nicholas Ghionni (@pulmtoilet), a first-year attending at the MedStar Baltimore Hospital system. He completed PCCM fellowship at MedStar Washington Hospital Center where he also served as chief fellow.

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Lightning rounds 39: Understanding flight medicine with Jace Mullen

We explore critical care transport medicine from both a clinical and career perspective, including helicopters (HEMS), fixed wing jet, and ground ambulance transports, with Jace Mullen, flight paramedic and airway educator out of Denver.

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Lightning rounds 38: Working in APP leadership, with Jason Wieland

We talk about working in critical care APP leadership positions, with Jason Wieland, PA, Lead Pulmonary & Critical Care APP at WakeMed Health System in Raleigh, NC.

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Lightning rounds 37: Weaning the deliriosedated patient (SCCM roundup)

A roundup of opinions from attendees at SCCM’s 2024 Critical Care Congress in Phoenix on strategies for rescuing the patient stuck in a loop of deep sedation and agitation.

Thanks to Pat Posa, Martha Roberts, Juliana Barr, Kelly Drumright, and Ben Lassow for their input.

Resources

  1. ICU Liberation.org
  2. ICU Delirium
  3. ICU Rehab Network

Lightning rounds 36: Nurses are from Venus

Bedside nurses and providers (physicians, PAs, NPs) tend to see the world differently, much of it driven by their training and the systems they work within. We chat about reconciling this and how to best function as a team.

Lightning rounds #35: Brain death updates, with Ariane Lewis and Matthew Kirschen

Discussing the new 2023 AAN/AAP/CNS/SCCM Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Practice Guideline, with the joint first authors: Dr. Ariane Lewis, neurointensivist, professor of neurology and neurosurgery at NYU Langone, director of neurocritical care, and chair of the Langone ethics committee, and Dr. Matthew Kirschen, pediatric neurointensivist and associate director of pediatric neurocritical care at the Children’s Hospital of Philadelphia.

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Takeaway lessons

  1. Ancillary testing (the idea of “confirmatory” testing is not optimal) is not a replacement for the clinical exam, and any confounding factors to the exam that can be corrected (for example, by waiting longer for temperature or drugs to normalize) must beā€”this cannot be bypassed by skipping to an ancillary test.
  2. Drug levels that may confound the exam should be measured whenever possible, and when there is doubt or question, the monitoring period should be increased, even if this delays the time until declaration of death.
  3. Drug use that results in clear anoxic brain injury can be compatible with declaring brain death based on the later, even if the exact nature of the former is not established.
  4. Temperature must be above 36c during the exam, and above 35.5c for the last 24 hours.
  5. Brain death testing in the setting of anoxia after cardiac arrest should be delayed for at least 24 hours after arrest.
  6. A minimum of one clinical exam should be performed in adults, but one or more additional exams may be useful. A minimum of two are recommended in pediatrics. Local protocol should be followed. No specific interval of waiting between exams is recommended in adults (the important “waiting” should occur prior to performing the first exam), although a 12-hour minimum interval in pediatrics is recommended, mainly for historical reasons.
  7. Advanced practice providers may perform the exam if appropriately trained and credentialed.
  8. EEG is not recommended as an ancillary test, mainly because it primarily gives information on cortical electrical activity, which adds relatively little to a confounded clinical examination. Bloodflow tests like nuclear scintigraphy say something about perfusion to the brain (particularly when a lateral view is used), which is useful.
  9. Brain death testing must be done 100% right, 100% of the time. All providers should follow hospital policy and state law, not just guidelines when there is conflict. Ideally the two will match, but this can take time to catch up when new guidelines are released.

Lightning rounds #34: … When?

When should you…

  • Update family on clinical changes
  • Call a consult
  • Notify a nurse about new orders
  • Communicate with an attending

Lightning rounds #33: Transitioning to academics with Janelle Bludorn

We chat with Janelle Bludorn (@JanelleRBlu), former emergency medicine PA, Assistant Professor and Academic Coordinator at the Duke PA program, about transitioning from clinical work into teaching and academia.

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Resources

  1. Harvard Macy Institute
  2. Duke Ahead
  3. UNC Center for Faculty Excellence
  4. PAEA Jobs board
  5. NONPF Jobs board

Lightning rounds #32: Creating a POCUS system with Leon Chen

We chat with Leon Chen about his work setting up infrastructure for clinical POCUS at Memorial Sloan Kettering. Leon is an Adult/Gerontology Acute Care Nurse Practitioner in the ICU, Clinical Program Manager of Research and Simulated Learning, and an Associate Professor at Columbia University School of Nursing.

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References

  1. Leon’s recent paper: Point-of-care Ultrasound (POCUS) Program for Critical Care Nurse Practitioners and Physician Assistants in an Oncological Intensive Care Unit and Rapid Response Team