Critical Care Physicians Research Articles

Management of adult patients with haematological malignancies in critical care.

There are a diverse range of haematological malignancies with varying clinical presentations and prognoses. Patients with haematological malignancy may require admission to critical care at the time of diagnosis or due to treatment related effects and complications. Although the prognosis for such patients requiring critical care has improved, there remain uncertainties in optimal clinical management. Identification of patients who will benefit from critical care admission is challenging and selective involvement of palliative care may help to reduce unnecessary and non-beneficial treatments. While patients with haematological malignancy can present a challenge to critical care physicians, good outcomes can be achieved. In this narrative review, we provide a brief overview of relevant haematological malignancies for the critical care physician and a summary of recent treatment advances. Subsequently, we focus on critical care management for the patient with haematological malignancy including sepsis; acute respiratory failure; prevention and treatment of tumour lysis syndrome; thrombocytopaenia; and venous thromboembolism. We also discuss immunotherapeutic-specific related complications and their management, including cytokine release syndrome and immune effector cell associated neurotoxicity syndrome associated with chimeric antigen receptor T-cell therapy. While the management of haematological malignancies is highly specialised and increasingly centralised, acutely unwell patients often present to their local hospital with complications requiring critical care expertise. The aim of this review is to provide a contemporary overview of disease and management principles for non-specialist critical care teams.

Viral infections in critical care: a narrative review.

Viral infections form a substantial part of the intensive care workload, even before the recent and ongoing COVID-19 pandemic. The growing availability of molecular diagnostics for viral infections has led to increased recognition of these pathogens. This additional information, however, provides new challenges for interpretation and management. As the SARS-CoV-2 pandemic has amply demonstrated, the emergence and global spread of novel viruses are likely to provide continued challenges for critical care physicians into the future. This article will provide an overview of viral infections relevant to the critical care physician, discussing the diagnosis and management of respiratory viral infections, blood borne and enteric viruses. We will also discuss herpesviridae complications, commonly seen due to reactivation of latent infections. Further, we explore some rarer and emerging viruses, including recognition of viral haemorrhagic fevers, and briefly discuss post-viral syndromes which may present to the intensive care unit. Finally, we will discuss infection control and its importance in preventing nosocomial viral transmission.

Mixed-methods process evaluation of a respiratory-culture diagnostic stewardship intervention.

To conduct a process evaluation of a respiratory culture diagnostic stewardship intervention. Mixed-methods study. Tertiary-care pediatric intensive care unit (PICU). Critical care, infectious diseases, and pulmonary attending physicians and fellows; PICU nurse practitioners and hospitalist physicians; pediatric residents; and PICU nurses and respiratory therapists. This mixed-methods study was conducted concurrently with a diagnostic stewardship intervention to reduce the inappropriate collection of respiratory cultures in mechanically ventilated children. We quantified baseline respiratory culture utilization and indications for ordering using quantitative methods. Semistructured interviews informed by these data and the Consolidated Framework for Implementation Research (CFIR) were then performed, recorded, transcribed, and coded to identify salient themes. Finally, themes identified in these interviews were used to create a cross-sectional survey. The number of cultures collected per day of service varied between attending physicians (range, 2.2-27 cultures per 100 days). In total, 14 interviews were performed, and 87 clinicians completed the survey (response rate, 47%) and 77 nurses or respiratory therapists completed the survey (response rate, 17%). Clinicians varied in their stated practices regarding culture ordering, and these differences both clustered by specialty and were associated with perceived utility of the respiratory culture. Furthermore, group "default" practices, fear, and hierarchy were drivers of culture orders. Barriers to standardization included fear of a missed diagnosis and tension between practice standardization and individual decision making. We identified significant variation in utilization and perceptions of respiratory cultures as well as several key barriers to implementation of this diagnostic test stewardship intervention.

“The Weight of the Pager on My Hip”: Lightening the Load of Empathy on Critical Care Physicians by Understanding its Limitations, A Qualitative Study

Introduction: Empathy improves patient outcomes and increases perception of physician competence. However, empathy may contribute to biased decision-making and provider burnout. To help providers harness the benefits of empathy without the pitfalls, comprehensive knowledge about the practice of empathy is needed – particularly in high-stress contexts, such as in critical care. This qualitative study explores how critical care physicians experience empathy in intensive care units and how this might inform the medical education of critical care physicians throughout their training. Methods: Working from a constructivist orientation, we engaged in thematic analysis of semi-structured interviews with critical care physicians. We asked participants to describe their personal experiences of empathy including how they handled events requiring empathy, managed empathic distress, and reframed their understanding of empathy over time. Data analysis followed the six steps of thematic analysis and used Hoffman’s Theory of Empathy to further inform our understanding of the data. Results: We identified limitations of empathy in the intensivist experience, which were consistent with Hoffman’s theory of empathy. This theory describes arousal, habituation, and bias which were prevalent in the data. Further, intensivists altered their behavior due to these limitations and to manage empathic distress. Additionally, burnout as a consequence of empathy was identified, though interviewees discussed prevention methods and the development of resilience. Discussion: Empathy and empathic distress among intensivists have been understudied in the literature thus far. Our study reveals that critical care physicians acutely experience limitations of empathy to include over-arousal, habituation, and bias—all of which impact interactions with patients, physician stress, and physician burnout. The knowledge that fully trained intensivists struggle with the limitations of empathy has implications to all stages of physician education from medical student through continuing medical education for attendings since all must learn and practice the empathic skills required to optimize patient care and maintain their own wellness.

Challenges hindering emergency physicians; involvement in multicenter collaborative studies in Japan: A nationwide survey analysis.

Multicenter collaborative research accelerates patient recruitment and strengthens evidence. Nevertheless, the factors influencing emergency and critical care physicians' involvement in such research in Japan remain unclear. A nationwide web-based survey conducted in early 2023 targeted emergency physicians working a minimum of 3 days per week in Japan. The survey descriptively assessed their backgrounds, work and research environments, experiences, and perceived impediments and motivators for multicenter research. Of the 387 respondents, 348 were included in the study, yielding a 5.1% response rate. Women comprised 11% of the participants; 33% worked in university hospitals, 65% served in both emergency departments and intensive care units, and 54% did shift work. Only 12% had designated research time during working hours, with a median of 1 hour per week (interquartile range 0-5 h), including time outside of work. While 73% had participated in multicenter research, 58% noted barriers to participation. The key obstacles were excessive data entry (72%), meeting time constraints (59%), ethical review at each facility (50%), and unique sample collection, such as bronchoalveolar lavage specimens or pathological tissues (51%). The major incentives were networking (70%), data sets reuse (65%), feedback on research results (63%), and recognition from academic societies (63%). Financial rewards were not highly prioritized (38%). While valuing clinical research, emergency physicians face barriers, especially data entry burden and limited research time. Networking and sharing research findings motivate them. These insights can guide strategies to enhance collaborative research in emergency and critical care in Japan.

137: AUTOMATE TO RESUSCITATE: OUTCOMES OF MECHANICAL CPR TWO YEARS AFTER ACUTE CARE IMPLEMENTATION

Introduction: Expert Guidelines endorsed Mechanical Cardiopulmonary Resuscitation (mCPR) devices in response to the COVID-19 pandemic. In April, 2020, a regional hospital received grant-funding for mCPR devices to reduce team exposure during CPR events. Methods: We aimed to evaluate patient outcomes and teammate perceptions associated with mCPR. The primary clinical outcome measured was 1 hour survival post CPR event among inpatients experiencing a cardiopulmonary arrest before & after mCPR implementation, including subset analysis of CPR events where mCPR was specifically noted as being used. Teammate perceptions comparing resuscitation events with and without the mCPR device, barriers to use, and impact on communication and teamwork were assessed using an electronic survey approximately one year post-implementation. Results: Respondents to the team survey (n=22) were primarily nurses (81%) in the critical care unit or the critical care code team, Respiratory Therapists (9.5%) & physicians or APPs (9.5%). One third of participants self-reported using the mCPR device 60% or more of the time. Most (72%) indicated a reduction in teammates required in the room for CPR events in the ICU. Participants rated improvement in communication and ability to focus on their role during a Code Blue. Most (76%) “Agreed” or “Strongly Agreed” that the quality of resuscitation is improved when the mCPR is in use. We defined event survival as return of spontaneous circulation (ROSC) plus survival >1 hour after the CPR event to align with historic institutional data. Baseline survival (2019) at 1 hour across all inpatient areas was 53.1%. During the 2 years post-implementation, inpatient event survival was similar at 52.9% with confirmed mCPR. In critical care, post implementation non-mCPR codes had 54.2% survival compared with 57.14% confirmed mCPR ICU Codes. mCPR was documented only in about 8% of ICU and non-ICU codes. Data are limited by onconsistent documentation of mCPR Utilization. Measures were implemented May 1 2022 and following to better capture utilization. Conclusions: Staff report benefits with mCPR. mCPR outcomes should be monitored as a variable in ongoing quality improvement. Further study of quantitative outcomes with subgroup analysis & staff perception of mCPR devices in inpatient CPR events is needed.

577: ADDRESSING PATIENT AND FAMILY SPIRITUAL NEEDS: A NATIONAL NEEDS ASSESSMENT OF PEDIATRIC FELLOWS

Introduction: Spiritual care is an essential component of whole-person healthcare and becomes increasingly important in critical situations. Despite practice guidelines from the American College of Critical Care Medicine, studies have shown that adult critical care physicians rarely initiate conversations about patients’ and families’ spiritual needs and cite lack of training as a significant barrier. Little is known about the perspectives of pediatric physicians working in critical care settings as they relate to spiritual care. Methods: An IRB-approved survey was sent to 720 pediatric fellows training in critical care settings (165 Cardiology, 259 Critical Care, 296 Neonatology). Categorical data was compared using chi-squared test or Fisher’s exact tests. The Wilcoxon rank sum test was used to compare the percentage correct on ten multiple-choice questions about world religions. Written free text responses were independently reviewed and coded using inductive analysis by two research investigators. Results: 245 surveys were completed yielding a 34% response rate. 83% of fellows had never received prior spiritual care training and 72% of fellows indicated that they would be somewhat or very likely to incorporate spiritual care into their practice if they received training. Prior training was significantly associated with increased knowledge of a framework for taking a spiritual history (p < 0.001), the spiritual care resources at the fellow’s institution (p < 0.004), and spiritual practices that could influence medical care (p < 0.029). Prior training was significantly associated with frequency of taking a spiritual history (p < 0.0001), comfort taking a spiritual history (p < 0.0001), and referring patients/families to spiritual care resources (p < 0.016). Lack of time and training were the most commonly reported barriers to providing spiritual care in qualitative responses. Conclusions: Providing spiritual care for families is important in critical care. Pediatric fellows are open to incorporating spiritual care into their practice but lack the training to do so. Prior training is significantly associated with improved knowledge and skills in providing spiritual care. An opportunity exists to implement spiritual care training into pediatric training programs.

Integrating machine learning predictions for perioperative risk management: Towards an empirical design of a flexible-standardized risk assessment tool

BackgroundSurgical patients are complex, vulnerable, and prone to postoperative complications that can potentially be mitigated with quality perioperative risk assessment and management. Several institutions have incorporated machine learning (ML) into their patient care to improve awareness and support clinician decision-making along the perioperative spectrum. Recent research suggests that ML risk prediction can support perioperative patient risk monitoring and management across several situations, including the operating room (OR) to intensive care unit (ICU) handoffs. ObjectivesOur study objectives were threefold: (1) evaluate whether ML-generated postoperative predictions are concordant with clinician-generated risk rankings for acute kidney injury, delirium, pneumonia, deep vein thrombosis, and pulmonary embolism, and establish their associated risk factors; (2) ascertain clinician end-user suggestions to improve adoption of ML-generated risks and their integration into the perioperative workflow; and (3) develop a user-friendly visualization format for a tool to display ML-generated risks and risk factors to support postoperative care planning, for example, within the context of OR-ICU handoffs. MethodsGraphical user interfaces for postoperative risk prediction models were assessed for end-user usability through cognitive walkthroughs and interviews with anesthesiologists, surgeons, certified registered nurse anesthetists, registered nurses, and critical care physicians. Thematic analysis relying on an explanation design framework was used to identify feedback and suggestions for improvement. Results17 clinicians participated in the evaluation. ML estimates of complication risks aligned with clinicians' independent rankings, and related displays were perceived as valuable for decision-making and care planning for postoperative care. During OR-ICU handoffs, the tool could speed up report preparation and remind clinicians to address patient-specific complications, thus providing more tailored care information. Suggestions for improvement centered on electronic tool delivery; methods to build trust in ML models; modifiable risks and risk mitigation strategies; and additional patient information based on individual preferences (e.g., surgical procedure). ConclusionsML estimates of postoperative complication risks can provide anticipatory guidance, potentially increasing the efficiency of care planning. We have offered an ML visualization framework for designing future ML-augmented tools and anticipate the development of tools that recommend specific actions to the user based on ML model output.Statement of Significance.•Problem: Implementation of machine-learning (ML) output within clinical workflows is not trivial.•What is already known: Barriers to ML implementation and appropriate use within clinical workflows include clinicians’ limited understanding of ML, wariness of ML output, and lack of ML output actionability.•What this paper adds: Qualitative end-user evaluation of postoperative risk predictions found high-levels of agreement between rankings of clinicians' manual risk rankings and ML-augmented risk estimates. The evaluation also highlighted design (functional and visual) enhancements for translational implementation of ML models within clinical workflows.

Sacrifices

Sacrifices Efrat Lelkes I've always been goal-oriented. Since I was a teenager, I've known what my life would look five, ten years ahead of time. I went straight through—straight to college from high school, to medical school, through residency, fellowship, and to a junior faculty position in academia. I never stopped to ask if this was the right path for me, nor did I ask what I was missing throughout this path. For me, the honor of being in academia meant that I kept going without questioning. I theoretically knew that sacrifices were intrinsic to becoming a physician, especially a physician-scientist. But to be an academician, I believed, was what I was supposed to be, and thus I knew that I would sacrifice sleep, money, and a "normal life" for a long time. I just didn't realize that I would sacrifice myself. In my mid-thirties, I began to recognize that the life I had forged as a physician-scientist was destroying me. I hated being in the lab. I missed my patients. I spent my time away from work living a very unhealthy life. And so, abruptly, I left the lab and my career as a scientist, and I transitioned to being a full-time pediatric critical care physician. I did so with the belief that I was a failure. I did so without considering the need to care for myself and to truly ask what I needed. I just believed I needed to serve others. The pressure I put on myself was immense. I started to mistrust myself as a clinician. I started to make mistakes. I deeply despised myself. And then I broke. With severe depression and anxiety, post-traumatic stress disorder, and a need to run away, I left home for a year under the guise of further training in palliative medicine. It was the year that saved my life, and it was the year that I began to appreciate how much I had given up for this career. It was when I learned that academia was not life, and it was then that I learned what I truly wanted. I wanted a family. I had wasted so much time pretending that I didn't. No glory had been afforded—especially for young women in this world—to needing a companion. I was supposedly superhuman; I didn't need anyone else—whenever anyone asked what was wrong, I would defiantly aver that I was fine—and to suggest otherwise meant that I was a burden and useless. But, by my late thirties, after my year away, after starting to heal, I was learning otherwise. I wanted to belong and to connect. I wanted a partner. Just as much, I wanted to become a mom. So I entered the world of fertility, deciding to become a single mom by choice. My reproductive endocrinologist was remarkable, my friends and my family were supportive, and I felt courageous, proud, and ready. [End Page E16] And, just as I started this process alone, I fell in love for the first time. I met a man the same month I started to try to get pregnant through Intrauterine Insemination (IUI). The first cycle did not work. I was sad, and he supported me. The second cycle did not work, and I was relieved. He was as well. We were becoming part of each other's lives, and we were excited about the future. I chose to put motherhood aside to focus on us, in theory. But, in truth, it was hard not to think about it daily. I knew that I was getting to the end of my reproductive years. Though I wanted a fairy tale, and I wanted us to be together, the aching to be a mom would not subside. I tried to quash it, but it would bubble up, and it would explode. I should have listened to him when he told me he was not ready. We perhaps should have made different decisions about our relationship. But we were deeply in love, we believed in us, so we forged ahead. After an eternity of pressure by me—and pressure fueled by...

An Educational Video Demonstration of How to Prone a Critically Ill Intubated Patient

Early in the coronavirus disease 2019 (COVID-19) pandemic, it was reported that prone position was beneficial for mechanically ventilated COVID-19 patients with acute respiratory distress syndrome (ARDS). However, for staff in some small and large hospitals, experience with this intervention was low. Select hospitals were able to assemble proning teams; but, as facilities began to experience staffing shortages, they found proning teams unsustainable, and less specialized staff needed to learn how to safely prone patients. Proning is a high-risk procedure-a lack of a standard approach can result in staff confusion and poor patient outcomes, including unintentional endotracheal tube (ET) loss, vascular access dislodgement, and skin breakdown. Given the acuity and high patient volume, translating a complex procedure into written policy may not be entirely effective. Critical care nurses, respiratory therapists, physical therapists, wound nurses, nurse practitioners, physician assistants, and medical doctors need to be prepared to safely perform this procedure for an acutely ill COVID-19 patient. Communication, teamwork, and multidisciplinary collaboration are critical for complication avoidance. Interventions to prevent tube and vascular access dislodgement, skin breakdown, and brachial plexus and soft tissue injury must be implemented during the procedure. Repositioning the patient in the prone position, as well as returning the patient to supine positioning, should be components of a comprehensive proning plan.

Exploring the Impacts of the Beginning of the COVID-19 Pandemic on Critical Care Physicians and the Delivery of Patient Care in Eight Countries: A Qualitative Interview-Based Study

Purpose: To understand critical care physician experiences across multiple countries with the COVID-19 pandemic to inform future pandemic preparedness planning. Methods: In this qualitative descriptive study, 16 critical care physicians (from eight countries) identified in convenience and purposive sampling took part in individual semi-structured interviews from April 7, 2020 to August 27, 2020 that captured the first wave of the pandemic. Open coding was conducted by two researchers who facilitated inductive thematic analysis. Results: Key themes identified following thematic analysis included the following: (a) sourcing and implementation of trusted information; (b) health systems–level preparedness with accessible supports; (c) institutional adaptations, including changes to patient care; (d) professional safety and occupational well-being; (e) triage and restricted visitation policies; and (f) managing personal familial responsibilities. Conclusion: The COVID-19 pandemic transformed the ways in which critical care physicians cared for their patients and personally coped with challenges. Perspectives of critical care physicians are important for ongoing pandemic planning and should be included in future pandemic policy development.

Reviewing COVID-19 from an anesthesiologist's perspective in 2022: JA symposium.

The COVID-19 pandemic is ongoing as of September 2022. Since January 2020 when the first case was reported in Japan, the medical community faced a variety of problems both domestically and internationally. It is meaningful to review the impact of COVID-19 from an anesthesiologist's perspective to clarify our policy for future infectious disease outbreaks. In this year's Journal of Anesthesia (JA) symposium, five experts who were deeply involved in the COVID-19 response reviewed the past 2.5years and made recommendations for potential future pandemics. Anesthesiologists are specialists in airway management and their role in intubating patients with COVID-19 has received much attention. However, they have also played an important backup role in intensive care as critical care physicians and must be more involved in critical care in regular (non-pandemic) times to properly fulfill this role. It is especially important for the Japan Society of Anesthesiologists and JA to quickly disseminate accurate information on unknown infectious diseases to the medical community and wider society. Therefore, it is important to promptly publish papers that are quality-assured through peer review.

ECMO During COVID-19: A Society of Thoracic Surgeons/Extracorporeal Life Support Organization Survey

BackgroundThe Society of Thoracic Surgeons Workforce on Critical Care and the Extracorporeal Life Support Organization sought to identify how the coronavirus disease 2019 (COVID-19) pandemic has changed the practice of venoarterial (VA) and venovenous (VV) extracorporeal membrane oxygenation (ECMO) programs across North America. MethodsA 26-question survey covering 6 categories (ECMO initiation, cannulation, management, anticoagulation, triage/protocols, and credentialing) was emailed to 276 North American Extracorporeal Life Support Organization centers. ECMO practices before and during the COVID-19 pandemic were compared. ResultsResponses were received from 93 (34%) programs. The percentage of high-volume (>20 cases per year) VV ECMO programs increased during the pandemic from 29% to 41% (P < .001), as did institutions requiring multiple clinicians for determining initiation of ECMO (VV ECMO, 25% to 43% [P = .001]; VA ECMO, 20% to 32% [P = .012]). During the pandemic, more institutions developed their own protocols for resource allocation (23% before to 51%; P < .001), and more programs created sharing arrangements to triage patients and equipment with other centers (31% to 57%; P < .001). Direct thrombin inhibitor use increased for both VA ECMO (13% to 18%; P = .025) and VV ECMO (12% to 24%; P = .005). Although cardiothoracic surgeons remained the primary cannulating proceduralists, VV ECMO cannulations performed by pulmonary and critical care physicians increased (13% to 17%; P = .046). ConclusionsThe Society of Thoracic Surgeons/Extracorporeal Life Support Organization collaborative survey indicated that the pandemic has affected ECMO practice. Further research on these ECMO strategies and lessons learned during the COVID-19 pandemic may be useful in future global situations.

Agitation is a Common Barrier to Recovery of ICU Patients.

Importance: Agitation is common in mechanically ventilated ICU patients, but little is known about physician attitudes regarding agitation in this setting. Objectives: To characterize physician attitudes regarding agitation in mechanically ventilated ICU patients. Design, Setting, and Participants: We surveyed critical care physicians within a multicenter health system in Western Pennsylvania, assessing attitudes regarding agitation during mechanical ventilation and use of and confidence in agitation management options. We used quantitative clinical vignettes to determine whether agitation influences confidence regarding readiness for extubation. We sent our survey to 332 critical care physicians, of whom 80 (24%) responded and 69 were eligible (had cared for a mechanically ventilated patient in the preceding three months). Main Outcomes and Measures: Respondent confidence in patient readiness for extubation (0-100%, continuous) and frequency of use and confidence in management options (1-5, Likert). Results: Of 69 eligible responders, 61 (88%) agreed agitation is common and 49 (71%) agreed agitation is a barrier to extubation, but only 27 (39%) agreed their approach to agitation is evidence-based. Attitudes regarding agitation did not differ much by practice setting or physician demographics, though respondents working in medical ICUs were more likely (P = .04) and respondents trained in surgery or emergency medicine were less likely (P = .03) than others to indicate that agitation is an extubation barrier. Fifty-three (77%) respondents reported they frequently use non-pharmacologic measures to treat agitation, and 42 (70%) of those who reported they used non-pharmacologic measures during the prior 3 months indicated confidence in their effectiveness. In responses to clinical vignettes, confidence in patient's readiness for extubation was significantly lower if the patient was agitated (P < .001) or tachypneic (P < .001), but the presence of both agitation and tachypnea did not reduce confidence compared with tachypnea alone (P = .24). Conclusions and Relevance: Most critical care physicians consider agitation during mechanical ventilation a common problem and agreed that agitation is a barrier to extubation. Treatment practice varies widely.

Informal and Incidental Learning in Complex Clinical Environments: An Examination of Critical Incidents of Frontline Physicians During the COVID-19 Pandemic and Implications for Medical Education.

Purpose: The uncertainty and complexity of everyday clinical practice was amplified by the COVID-19 pandemic and illuminated the gap in training that students receive to function in uncertain environments. To date, formal training to navigate uncertainty in practice is lacking. Educators require an understanding of informal and incidental learning (IIL) to prepare students for this uncertainty. Learning in the clinical environment, long described as informal, represents a process for learning that is implicit, unintended, opportunistic, and unstructured. The authors explore IIL as a guiding framework for developing a curriculum that prepares students to navigate uncertainty. Method: Using a constructivist grounded theory approach, we describe physicians’ IIL while working during times of heightened uncertainty. The critical incident technique was used to elicit narratives from 6 frontline emergency medicine and 6 critical care physicians who worked during the height of the pandemic (March–June 2020) and asked them to describe their learning in the clinical environment. Interviews were virtual, recorded, and transcribed. We re-storied narratives to build a cohesive, chronological story in the participants’ own words. We reviewed re-storied narratives as part of an inductive analysis, which allowed for the collection of patterns, assertions, and organizing themes. We examined what participants did in the face of uncertainty and how IIL manifests in their narratives. Results: Physicians were challenged by not being able to rely on evidence-based medicine. Physicians reported an increased reliance on the interprofessional team (specifically, nursing colleagues) to overcome fears of failure. They highlighted the importance of team consensus and agreement as they learned how to care for COVID-positive patients. Their learning was characterized by “pattern recognition” (i.e., known procedures of care), “intuition” (i.e., gut feeling), and reliance on past experiences (i.e., “new things are just new versions of old things”). In many instances, participants had to comfortably engage in “poking at the periphery” (i.e., trial and error) and “pivoting on the fly” (i.e., making do with the information and/or equipment available) to navigate their learning. Physicians relied on consensus building, previous knowledge and expertise, and abductive problem solving to navigate uncertainty in their clinical practice. Discussion: Physicians’ critical incidents provide rich data to clarify our understanding of what IIL looks like in the clinical context when working through uncertainty. Physicians relied on consensus building, previous knowledge and expertise, and abductive problem solving to navigate uncertainty in their clinical practice. Significance: Our findings may inform educational interventions that prepare medical students to navigate uncertainty in clinical practice. There are opportunities in medical education to cultivate skills in formal curriculum, to prime students for IIL, so they are better prepared to navigate situations of clinical uncertainty.

Identifying Paths Forward: Expanding Palliative Care to Low-Income Patients in California.

Multiple studies demonstrate most consumers do not know about palliative care. And, since January 2018, California's Medi-Cal Managed Care patients have been eligible for palliative care services under Senate Bill 1004 (SB 1004). Yet, the uptake of palliative care services was underwhelming. The purpose of this study was to explore patient-centered barriers to palliative care. We recruited 27 adult Medicaid managed care patients from community-based sites in Los Angeles and conducted semi-structured qualitative interviews. Each participant was asked questions to elicit their knowledge about, and perspectives on, palliative care as well as their preferred communication approaches for receiving a referral to palliative care. The interviews were audio-recorded and transcribed verbatim. We used a grounded theory approach to guide our analysis of primary themes. Our findings indicated that the barriers to palliative care referrals among this population included lack of knowledge about palliative care and available services; the reliance on, and trust in, primary care physicians for information; language and cultural barriers; housing instability; and patient believing they are neither old enough nor sick enough to need palliative care. These findings emphasize the critical role primary care physicians play in advocating for low-income patients and the necessity for culturally sensitive education about palliative care. Promoting knowledge and understanding of palliative care among both primary care physicians and consumers is critical to ensuring access to care.

SEROPOSITIVE MYASTHENIA GRAVIS AS THE CAUSE OF MULTIPLE FAILED EXTUBATIONS AND A PROLONGED ICU STAY FOR COVID-19 PNEUMONIA: A CASE REPORT AND BRIEF LITERATURE REVIEW

SEROPOSITIVE MYASTHENIA GRAVIS AS THE CAUSE OF MULTIPLE FAILED EXTUBATIONS AND A PROLONGED ICU STAY FOR COVID-19 PNEUMONIA: A CASE REPORT AND BRIEF LITERATURE REVIEW

MELIOIDOSIS: THE "GREAT MIMICKER"

SESSION TITLE: Pulmonary Manifestations of Infections SESSION TYPE: Case Reports PRESENTED ON: 10/17/2022 03:15 pm - 04:15 pm INTRODUCTION: Melioidosis, caused by Burkholderia pseudomallei, is often referred to as a "great mimicker” as it is often mis-diagnosed and under-reported due to its widely variable clinical presentation (1). Here we discuss a patient who presented with a constellation of symptoms that were mistaken for other disease processes prior to a melioidosis diagnosis. CASE PRESENTATION: A 71 year old male of Haitian descent with recent travel to Haiti presented with >1 month of persistent fevers and worsening diffuse weakness and arthralgias. The patient was first empirically treated for Q fever with doxycycline and hydroxychloroquine at a different hospital prior to presentation. Upon presentation to this facility, he underwent further work-up for a variety of infectious etiologies including chikungunya, malaria, and lyme disease due to his presentation with a multi-system process and recent travel. The patient's blood and joint aspirate cultures returned positive for Burkholderia pseudomallei and he was subsequently diagnosed with melioidosis. He was discharged on long-term antibiotic treatment with meropenem. The patient then re-presented to the ED approximately a week after discharge with signs of worsening disease including bilateral multifocal pneumonia. Imaging showed multiple pneumothoraces complicated by lung collapse and respiratory failure. The patient also had worsening neurological manifestations and further bone and joint involvement. CDC analysis of cultures identified resistance to meropenem. The patient was switched to ceftazidime and trimethoprim-sulfamethoxazole before escalation to imipenem. The patient expired six weeks from initial presentation due to worsening pulmonary and neurologic manifestations. DISCUSSION: As of 2020, only one confirmed case of melioidosis has been documented in the U.S. since 1945 (2). The incidence of this infection is reportedly increasing throughout the world and regions of endicimity are expanding. Its difficulty to diagnose contributes to a high mortality rate of 20-50% as of 2020 (2). 50% of patients will present with bacteremia and 20% of patients will progress to a fulminant septicemia (1). CONCLUSIONS: This case report identifies a case of melioidosis with both classic disease manifestations (pulmonary involvement), as well as less common manifestations (bone and joint involvement) and emphasizes the need for a broad differential when the patient presents with a non-specific, multi-organ clinical syndrome after travel. Although previously thought to be endemic only to Asian and Australian populations, more and more cases are being seen in South America, central America, and the Caribbean (2). With this being the case, the incidence of Melioidosis has the potential to increase in the U.S and further discussion of epidemiology, clinical presentation, and treatment is warranted for critical care, pulmonology, infectious disease, and primary care physicians. Reference #1: Chakravorty A, Heath CH. Melioidosis: An updated review. Australian Journal of General Practice. 2019;48(4):327-332. doi:10.31128/ajgp-04-18-4558 Reference #2: Gassiep I, Armstrong M, Norton R. Human melioidosis. Clinical Microbiology Reviews. 2020;33(2). doi:10.1128/cmr.00006-19 DISCLOSURES: No relevant relationships by Rose Puthumana No relevant relationships by Rachel Werne

Factors influencing prescribing by critical care physicians to heart failure patients in Egypt: a cross-sectional survey

BackgroundHeart failure (HF) guideline-led prescribing improves patient outcomes; however, little is known about the factors influencing guideline-led prescribing in critical care settings. This study used a cross-sectional survey to assess the factors that influence physicians when prescribing to heart failure patients in a critical care setting in Egypt.ResultsThe response rate was 54.8%. The international HF guidelines were the primary source of prescribing information for 84.2% of respondents. Staff were more familiar with the latest guideline recommendations than associate staff (86.7% vs 36.8%, p = 0.012) and considered patient’s perspectives more often (86.7% vs 26.3%, p = 0.036). Renal function was the clinical factor that most frequently influenced the prescribing of loop diuretics or renin–angiotensin–aldosterone system inhibitors. Pulmonary function influenced beta-blockers prescription. The most frequently cited barrier to guideline-led prescribing was the absence of locally drafted guidelines. A majority of prescribers agreed that implementation of clinical pharmacy services, physician education and electronic reminders may improve the implementation of guideline-led prescribing.ConclusionsAlthough experienced physicians are familiar with and use international guidelines, physicians would welcome local guidance on HF prescribing and greater clinical pharmacist input.

The theoretical and practical arguments against the unilateral withdrawal of life-sustaining treatment during crisis standards of care: Does the Knobe effect apply to unilateral withdrawal?

Some argue that it is ethically justifiable to unilaterally withdraw life-sustaining treatment during crisis standards of care without the patient's consent in order to reallocate it to another patient with a better chance of survival. This justification has been supported by two lines of argument: the equivalence thesis and the rule of the double effect. We argue that there are theoretical issues with the first and practical ones with the second, as supported by an experiment aimed at exploring whether the Knobe effect, which affects the folk concept of intention, applies to situations of unilateral withdrawal. Fifty-two critical care physicians from one university were asked to ascribe intention in two hypothetical scenarios A and B in which outcomes differ-the patient from whom life-sustaining treatment is withdrawn dies in scenario A but survives in scenario B-but the intention, to save the other patient regardless of the outcome of the other, is the same. The survey was administered via a web-based survey and all answers were anonymous. A paired proportion test was used to compare responses to both questions. All 52 surveyed individuals responded in scenario A and 30 (57.7%) ascribed intention when outcomes were unfavorable, whereas 50 responded in scenario B and 8 (16%) ascribed intention when outcomes were favorable, a difference that was statistically significant (p < 0.001). There are theoretical and practical issues with the arguments proposed to justify the unilateral withdrawal of life-sustaining treatment based on the equivalence thesis and the rule of double effect.