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Richard M. Schwartzstein, MD
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Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

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):547. doi:10.1378/chest.12-0935
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To the Editor:

I thank Dr Rascona for his comments on our article in CHEST1 regarding the causes of acute hypercapnia in the setting of an abdominal compartment syndrome. I agree that splanchnic hypoperfusion is a prominent feature of abdominal compartment syndrome, most commonly manifest as decreased urine output, which was masked in this case by the fact that the patient had chronic renal failure and was maintained on dialysis. However, I do not think that in the absence of an acute metabolic acidosis, hypoperfusion was the primary explanation for the rise in Paco2 in this particular case.

Dr Rascona also comments on the important role of supervision in the education of residents and our ability to provide high-quality patient care. Our institution, Beth Israel Deaconess Medical Center in Boston, Massachusetts, was the first academic medical center in our area to provide 24 h/d, on-site, critical care attending physicians for the ICUs. By allowing residents to evaluate patients (assuming patient acuity permits) prior to presenting the case to the supervising physician, we preserve and enhance the learning process while making clinical interventions in a timely manner. Furthermore, the threshold for a resident to ask for help appears to be far lower when the supervising physician is physically present in the medical center compared with when he/she is taking calls at home.

Although formal studies of the impact of more-consistent attending supervision of residents are just beginning to emerge, initial data show improved patient outcomes in the management of trauma2,3 and on general medical units.4 A systematic review of the topic evaluated 24 studies across a range of medical specialties and found evidence for improved patient and education outcomes.5

In the past 25 years, the provision of care in EDs has evolved considerably; patients once evaluated and treated in most hospitals by a range of part-time physicians trained in a range of fields are now primarily under the care of emergency medicine specialists. In the not-so-distant future, we can hope that patients in our ICUs can consistently receive care from critical care specialists.

Schwartzstein RM, Parker MJ. Rising Paco2in the ICU: using a physiologic approach to avoiding cognitive biases. Chest. 2011;140(6):1638-1642. [CrossRef] [PubMed]
 
Claridge JA, Carter JW, McCoy AM, Malangoni MA. In-house direct supervision by an attending is associated with differences in the care of patients with a blunt splenic injury. Surgery. 2011;150(4):718-726. [CrossRef] [PubMed]
 
Cohen R, Adini B, Radomislensky I, Givon A, Rivkind AI, Peleg K. Involvement of surgical residents in the management of trauma patients in the emergency room: does the presence of an attending physician affect outcomes?. World J Surg. 2012;36(3):539-547. [CrossRef] [PubMed]
 
O’Connor AB, Lang VJ, Bordley DR. Restructuring an inpatient resident service to improve outcomes for residents, students, and patients. Acad Med. 2011;86(12):1500-1507. [CrossRef] [PubMed]
 
Farnan JM, Petty LA, Georgitis E, et al. A systematic review: the effect of clinical supervision on patient and residency education outcomes. Acad Med. 2012;87(4):428-442. [CrossRef] [PubMed]
 

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References

Schwartzstein RM, Parker MJ. Rising Paco2in the ICU: using a physiologic approach to avoiding cognitive biases. Chest. 2011;140(6):1638-1642. [CrossRef] [PubMed]
 
Claridge JA, Carter JW, McCoy AM, Malangoni MA. In-house direct supervision by an attending is associated with differences in the care of patients with a blunt splenic injury. Surgery. 2011;150(4):718-726. [CrossRef] [PubMed]
 
Cohen R, Adini B, Radomislensky I, Givon A, Rivkind AI, Peleg K. Involvement of surgical residents in the management of trauma patients in the emergency room: does the presence of an attending physician affect outcomes?. World J Surg. 2012;36(3):539-547. [CrossRef] [PubMed]
 
O’Connor AB, Lang VJ, Bordley DR. Restructuring an inpatient resident service to improve outcomes for residents, students, and patients. Acad Med. 2011;86(12):1500-1507. [CrossRef] [PubMed]
 
Farnan JM, Petty LA, Georgitis E, et al. A systematic review: the effect of clinical supervision on patient and residency education outcomes. Acad Med. 2012;87(4):428-442. [CrossRef] [PubMed]
 
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