Building effective critical care teams.

Critical care is formulated and delivered by a team. Accordingly, behavioral scientific principles relevant to teams, namely psychological safety, transactive memory and leadership, apply to critical care teams. Two experts in behavioral sciences review the impact of psychological safety, transactive memory and leadership on medical team outcomes.

Dipyridamole-associated shock and pulmonary edema.

Objective: To report a case of fulminant shock and noncardiogenic pulmonary edema induced by intravenously administered dipyridamole.

Case Summary: A 73-year-old woman presented to the office of her cardiologist for dipyridamole myocardial scintigraphy. Several minutes after administration of intravenous dipyridamole 0.

A practical approach to adult acute respiratory distress syndrome.

Acute respiratory distress syndrome (ARDS) is a common disease encountered in hospitalized adult patients that, historically, has carried a very high mortality. This article reviews the clinical features and how pathophysiology informs the evidence-based management of ARDS.

Team science and critical care.

Because critical care is administered by multidisciplinary teams, it is plausible that behavioral methods to enhance team performance may impact the quality and outcomes of care. This review highlights the social and behavioral scientific principles of team building and briefly reviews four features of teams--leadership, psychological safety, transactive memory, and accountability--that are germane to critical care teams. The article highlights how team principles might be used to improve patient care and navigate hospital hierarchies, and concludes with implications for future educational and scientific efforts.

Are international and American graduates equally ACGME competent? Results of a pilot study.

Background: Despite a substantial proportion of international medical graduates (IMG) matching to U.S. programs in Internal Medicine, little is known about their readiness in the six medical competencies compared to graduates of U.

A randomized controlled trial of Child FIRST: a comprehensive home-based intervention translating research into early childhood practice.

This randomized, controlled trial was designed to document the effectiveness of Child FIRST (Child and Family Interagency, Resource, Support, and Training), a home-based, psychotherapeutic, parent-child intervention embedded in a system of care. Multirisk urban mothers and children, ages 6-36 months (N = 157) participated. At the 12-month follow-up, Child FIRST children had improved language (odds ratio [OR] = 4.

Elders' environs and their end-of-life preferences.

Hypothesis: Elders' predilections regarding end-of-life interventions vary with their living environs.

Methods: Patients in 3 settings--assisted living/outpatient, skilled nursing facility (SNF), and acute hospitalization--were asked to complete a brief questionnaire.

Results: A total of 269 patients who averaged 80.

Cardiac injury in patients with COPD presenting with dyspnea: a pilot study.

Purpose: The aim of this pilot study was to test the hypothesis that myocardial ischemia complicates the management of some patients with chest-pain-free chronic obstructive pulmonary disease (COPD) exacerbations.

Methods: In this prospective, observational, cohort study, patients admitted to a 350-bed community teaching hospital, with dyspnea and a primary diagnosis of COPD exacerbation, were followed for enzymatic and electrocardiographic evidence of myocardial ischemia for the first 24 hours of hospital admission.

Results: A total of 114 patients were studied.

Accuracy of bedside physical examination in distinguishing categories of shock: a pilot study.

Hypothesis: Selected elements of a simple physical examination algorithm accurately predict categories of shock.

Setting: A 350-bed community teaching hospital.

Methods: Resident trainees who manage all critically ill and medically unstable patients were instructed to document capillary refill, (palpated) pulse volume, skin temperature, jugular venous pressure (JVP) and lung examination in all patients with prolonged (>30 minutes hypotension <90 mmHg).

Atypical antipsychotic medications are independently associated with severe obstructive sleep apnea.

Background: Atypical antipsychotic (AA) medications are widely prescribed for their Food and Drug Administration-approved uses (acute mania, bipolar mania, psychotic agitation, bipolar maintenance, etc) and off-label indications. Although AA medications are associated with substantial weight gain, their tranquilizing effects may independently contribute to risk of obstructive sleep apnea (OSA) perhaps, by a reduction in activity of hypoglossal or recurrent activity of laryngeal nerve on the upper motor airway musculature.

Methods: We hypothesized that AA medications are associated with more severe OSA independent of weight and neck circumference.

Outcomes of critically ill patients who received cardiopulmonary resuscitation.

Rationale: Studies examining survival outcomes after in-hospital cardiopulmonary arrest (CPA) among intensive care unit (ICU) patients requiring medications for hemodynamic support are limited.

Objectives: To examine outcomes of ICU patients who received cardiopulmonary resusitation.

Methods: We identified 49,656 adult patients with a first CPA occurring in an ICU between January 1, 2000 and August 26, 2008 within the National Registry of Cardiopulmonary Resuscitation.

Gurgling breath sounds may predict hospital-acquired pneumonia.

Objectives: To determine whether gurgling sounds heard during speech or quiet breathing, with or without a stethoscope over the glottis, predict hospital-acquired pneumonia (HAP).

Methods: All patients admitted to the respiratory or general medicine ward of a 350-bed community teaching hospital were eligible. Patients were examined each day, and those who had upper airway gurgling, heard with or without the stethoscope, during breathing or speech at any point during admission were noted.

Enhanced end-of-life care associated with deploying a rapid response team: a pilot study.

Hypothesis: Institution of a rapid response team (RRT) improves patients' quality of death (QOD).

Setting: A 425-bed community teaching hospital.

Patients: : All medical-surgical patients whose end-of-life care was initiated on the hospital wards during the 8 months before (pre-RRT) and after (post-RRT) actuation.

Medical professionalism in the new millennium: are there intercultural differences? Brief report and commentary.

We hypothesized that differences in premedical and medical indoctrination might lead to demonstrable differences in notions of medical professionalism among U.S. medical schoolgraduates (USMG) and international medical graduates (IMG).

Outcomes of cardiopulmonary resuscitation for patients on vasopressors or inotropes: a pilot study.

Hypothesis: Outcomes of critically ill patients who receive cardiopulmonary resuscitation (CPR) are poor, and the subgroup on vasopressors or inotropes before cardiopulmonary arrest (CPA) rarely survives.

Setting: The setting of the study was a critical care unit of a 350-bed community teaching hospital.

Study Design: This was a retrospective, cohort study.

Rapid reversal of acute kidney injury and hospital outcomes: a retrospective cohort study.

Background: Acute kidney injury (AKI), defined as an increment in serum creatinine level of 0.3 mg/dL or greater in 48 hours, is associated with poor outcomes. The prognosis associated with an increased creatinine level, either on admission or that develops in the hospital (ie, AKI), that rapidly returns to normal is not known.

Why not physician-assisted death?

Objective: The Hippocratic Oath states "...

Acute kidney injury criteria predict outcomes of critically ill patients.

Objective: The Acute Kidney Injury Network's proposed definition for acute kidney injury (increment of serum creatinine > or = 0.3 mg/dL or 50% from baseline within 48 hrs or urine output < 0.5 mL/kg/hr for > 6 hrs despite fluid resuscitation when applicable) predicts meaningful clinical outcomes.

Patients' predilections regarding informed consent for hospital treatments.

Background: Respect for patient autonomy is a core principle of American medicine. Informed consent is required for surgical procedures and blood transfusions but not for most medical treatments of hospitalized patients.

Hypothesis: If given the option, patients want to give permission for common medical therapies during hospitalization.

Relevance and feasibility of multi-parameter assessment for management of mass casualties from a radiological event.

Objective: Local, regional, and federal response teams play an integrated role in the early management of mass casualties from a radiologic incident. Evaluation of individuals exposed to ionizing radiation requires an assessment of clinical signs and symptoms and an estimation of radiation dose. Here, we determine the relevance and feasibility of multi-parameter assessment for management of mass casualties from a radiological event.

The 9-11 Commission's invitation to imagine: a pathophysiology-based approach to critical care of nuclear explosion victims.

Objective: The successful management of mass casualties arising from detonation of a nuclear device (NDD) would require significant preparation at all levels of the healthcare system. This article briefly outlines previously published models of destruction and casualties, details approaches to on-site triage and medical evacuation, and offers pathophysiology-based suggestions for treatment of the critically injured. Documentation from previous bomb blasts and nuclear accidents is reviewed to assist in forecasting needs of both systems and patients in the event of an NDD in a major metropolitan area.