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Correspondence |

Complex Medical Decision-Making and Outcomes in the ICUComplex Medical Decision-Making in the ICU FREE TO VIEW

Dominick A. Rascona, MD, FCCP
Author and Funding Information

Financial/nonfinancial disclosures: The author has reported to CHEST the following conflicts of interest: Dr Rascona is engaged in tele-ICU research and development and serves on the Society of Critical Care Medicine Committee for Tele-ICU. He does not presently receive financial support or compensation for any tele-ICU-related activities.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2012;142(2):546-547. doi:10.1378/chest.12-0742
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To the Editor:

In an issue of CHEST (December 2011), Drs Schwartzstein and Parker1 made a particularly valuable contribution with an online diagram that well illustrates the rather difficult concept of inadvertent recruitment into zone 1 physiology while clearly dichotomizing the different effects of pressure- vs volume-driven mechanical ventilation. It should be considered invaluable for the initial teaching of medical students and junior house staff.

In addition to expert instruction regarding thoracic physiology and clinical decision-making, the authors’ instructive case study also depicts an arguably more important concept that deserves to be explicitly stated: This situation of difficult and disadvantageous intrathoracic ventilation, further confounded by an external resistive load (abdominal pressure), may have well led to an adverse or fatal outcome if left unrecognized for a further period of time. Instead, the situation was expertly managed by a well-functioning care system. For the arguably fortunate patient, the system was an expertly supervised on-site trainee model. Here, a sharp house officer recognized that something was awry despite stable hemodynamics and oxygenation. The house officer pursued the aberrancy as something potentially dangerous but beyond his or her scope of knowledge and experience. Importantly, the trainee accurately and reliably reported relevant information to the attending physician, who then immediately helped to guide the trainee toward a proper course of action.

Resolution of the patient’s hypercapnea in this case was likely coincident with the attenuation of something much more important, namely splanchnic hypoperfusion—the persistence of which may have led or contributed to multiorgan system failure. Furthermore, while the abdominal compartment syndrome was emphasized in this particular case, similar misunderstandings and/or underrecognition of complex relationships between intrathoracic gas and vascular pressures and volumes likely account for most cases of fatal asthma, poorer-than-necessary outcomes in cardiac resuscitation, and other suboptimal outcomes in emergency and critical care.

Unfortunately, a great many hospitals in the United States and elsewhere do not operate as described in the interactive physiology case. Economic or other conditions that preclude in-house 24 h/7 d (24/7) ICU coverage of any kind are surprisingly commonplace. Even if an on-site hospitalist is available, that person might be junior level, not yet board certified, not well trained in critical care, or simply too busy elsewhere in the hospital or ED to recognize and follow up on early; subtle; and, as in this case, complex, correctable physiologic disturbances.

Lack of 24/7 surveillance and management by on-site, adequately trained, and experienced intensivists is increasingly recognized as suboptimal care.2,3 Electronic surveillance and remote intervention in real time (the so-called tele-ICU) is likely a cost-effective alternative for units lacking house staff or otherwise unable to support 24/7 on-site intensivist coverage.4 For elaboration on this subject, Reynolds et al5 recently contributed a comprehensive description of available tele-ICU systems and models of care. The Society of Critical Care Medicine maintains a relatively new website dedicated solely to the principles and practice of tele-ICU.

If nothing else, a second set of eyes belonging to a board certified, fellowship-trained intensivist should provide peace of mind to patients, family members, and risk managers truly concerned about the outcomes of critically ill patients. With such a system in place, the question of whether anything else could have been done will almost certainly be answered in the reassuring negative.

Schwartzstein RM, Parker MJ. Rising Paco2in the ICU: using a physiologic approach to avoid cognitive biases. Chest. 2011;140(6):1638-1642. [CrossRef] [PubMed]
 
The Leapfrog Group. Purchasing principles The Leapfrog Group website.http://www.leapfroggroup.org/formembers/purchasing_principles. Accessed March 20, 2012.
 
Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA. 2002;288(17):2151-2162. [CrossRef] [PubMed]
 
Salam J, Van der Kloot TE. Tele-ICU: remote critical care telemedicine PCCSU Pulmonary Critical Care and Sleep Update, vol 24, lesson 13. American College of Chest Physicians website.http://www.chestnet.org/accp/pccsu/tele-icu-remote-critical-care-telemedicine. Accessed March 20, 2012.
 
Reynolds HN, Rogove H, Bander J, et al. A working lexicon for the tele-intensive care unit: we need to define tele-intensive care unit to grow and understand it. Telemed J E Health. 2011;17(10):773-783. [CrossRef] [PubMed]
 

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References

Schwartzstein RM, Parker MJ. Rising Paco2in the ICU: using a physiologic approach to avoid cognitive biases. Chest. 2011;140(6):1638-1642. [CrossRef] [PubMed]
 
The Leapfrog Group. Purchasing principles The Leapfrog Group website.http://www.leapfroggroup.org/formembers/purchasing_principles. Accessed March 20, 2012.
 
Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA. 2002;288(17):2151-2162. [CrossRef] [PubMed]
 
Salam J, Van der Kloot TE. Tele-ICU: remote critical care telemedicine PCCSU Pulmonary Critical Care and Sleep Update, vol 24, lesson 13. American College of Chest Physicians website.http://www.chestnet.org/accp/pccsu/tele-icu-remote-critical-care-telemedicine. Accessed March 20, 2012.
 
Reynolds HN, Rogove H, Bander J, et al. A working lexicon for the tele-intensive care unit: we need to define tele-intensive care unit to grow and understand it. Telemed J E Health. 2011;17(10):773-783. [CrossRef] [PubMed]
 
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