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Caring for patients with COVID-19 has resulted in a considerable strain on hospital capacity. One strategy to mitigate crowding is the use of ED-based observation units to care for patients who may have otherwise required hospitalization. We sought to create a COVID-19 Observation Protocol for our ED Observation Unit (EDOU) for patients with mild to moderate COVID-19 to allow emergency physicians (EP) to gather more data for or against admission and intervene in a timely manner to prevent clinical deterioration.This was a retrospective cohort study which included all patients who were positive for SARS-CoV-2 at the time of EDOU placement for the primary purpose of monitoring COVID-19 disease. Our institution updated the ED Observation protocol partway into the study period. Descriptive statistics were used to characterize demographics. We assessed for differences in demographics, clinical characteristics, and outcomes between admitted and discharged patients. Multivariate logistic regression models were used to assess whether meeting criteria for the ED observation protocols predicted disposition.During the time period studied, 120 patients positive for SARS-CoV-2 were placed in the EDOU for the primary purpose of monitoring COVID-19 disease. The admission rate for patients in the EDOU during the study period was 35%. When limited to patients who met criteria for version 1 or version 2 of the protocol, this dropped to 21% and 25% respectively. Adherence to the observation protocol was 62% and 60% during the time of version 1 and version 2 implementation, respectively. Using a multivariate logistic regression, meeting criteria for either version 1 (OR = 3.17, 95% CI 1.34-7.53, p0.01) or version 2 (OR = 3.18, 95% CI 1.39-7.30, p0.01) of the protocol resulted in a higher likelihood of discharge. There was no difference in EDOU LOS between admitted and discharged patients.An ED observation protocol can be successfully created and implemented for COVID-19 which allows the EP to determine which patients warrant hospitalization. Meeting protocol criteria results in an acceptable admission rate.

Rocuronium is increasingly used as a first-line neuromuscular blocker (NMB) in rapid sequence intubation by transport teams. Prior work has shown that rocuronium is associated with a delay in postintubation sedation compared with intubation with succinylcholine.Boston MedFlight is a consortium-based transport organization. In 2017, the intubation protocol and formulary for Boston MedFlight was changed to replace succinylcholine with rocuronium. We performed a retrospective review of patients intubated by the critical care transport teams from January 2017 through December 2019.We analyzed data for 264 intubations, 92 with succinylcholine and 172 with rocuronium. Ketamine and etomidate were the most common induction agents. The mean time from NMB administration to the first dose of sedation was 9.2 minutes (95% confidence interval, 5.4-23.7) for the succinylcholine cohort and 14.8 minutes (95% confidence interval, 8.4-38.0; P.001) for the rocuronium cohort. After neuromuscular blockade, the total hourly weight-adjusted fentanyl dose was significantly lower for patients intubated with rocuronium compared with succinylcholine.Intubation with rocuronium was associated with a longer time until the administration of sedation and decreased postneuromuscular blockade fentanyl administration compared with intubation with succinylcholine. These findings suggest opportunities for improvement in sedation and analgesia practices after rocuronium rapid sequence intubation.

Pulmonary hypertension (PH) is an important contributor to morbidity and mortality in patients seeking emergency care, resulting in high acuity presentations and resource utilization. The objective was to characterize the rate of intensive care unit (ICU) admission for PH among adult patients presenting to the emergency department (ED) along with other important clinical outcomes.We analyzed data from the State Emergency Department Databases (SEDD) and State Inpatient Databases (SID) from two geographically separated U.S. states (New York and Nebraska). The primary outcome measure was admission to an ICU. Other measures of interest included the hospital admission rate, hospital length of stay (LOS), inpatient mortality, and rate of critical care procedures performed.From 2010 to 2014, in a sample of 34 million ED visits, patients with a diagnosis of PH accounted for 0.71% of all ED visits. Of the PH visits, 20.2% were admitted to the ICU, compared to 2.6% of all other visits (P0.001), with an aOR of 1.74 (95% CI 1. 72-1.76). The vast majority (94.6%) of PH patients were admitted to the hospital, compared to 20.5% for all other ED visits (P0.001). Hospital LOS and hospital-based mortality were higher in the PH group than for other ED patients. With the exception of invasive mechanical ventilation, a significantly higher percentage of patients with PH admitted to the ICU than other patients underwent all critical care procedures evaluated.In this study, patients with PH who sought emergency care in U.S. EDs from 2010 to 2014 were significantly more likely to require ICU admission than all other patients. They were also significantly more likely to be admitted to the hospital than all other patients, had longer hospital LOS, increased risk of inpatient mortality, and underwent more critical care procedures. These findings indicate the high acuity of PH patients seeking emergency care and demonstrate the need for additional research into this population.

The severe acute respiratory syndrome coronavirus disease-2 (SARS-CoV-2) pandemic of 2020-2021 created unprecedented challenges for clinicians in critical care transport (CCT). These CCT services had to rapidly adjust their clinical approaches to evolving patient demographics, a preponderance of respiratory failure, and transport utilization stratagem. Organizations had to develop and implement new protocols and guidelines in rapid succession, often without the education and training that would have been involved pre-coronavirus disease 2019 (COVID-19). These changes were complicated by the need to protect crew members as well as to optimize patient care. Clinical initiatives included developing an awake proning transport protocol and a protocol to transport intubated proned patients. One service developed a protocol for helmet ventilation to minimize aerosolization risks for patients on noninvasive positive pressure ventilation (NIPPV). While these clinical protocols were developed specifically for COVID-19, the growth in practice will enhance the care of patients with other causes of respiratory failure. Additionally, these processes will apply to future respiratory epidemics and pandemics.

ObjectivesTo assess recent advances in interfacility critical care transport.Data sourcesPubMed English language publications plus chapters and professional organization publications.Study selectionManuscripts including practice manuals and standard (1990-2021) focused on interfacility transport of critically ill patients.Data extractionReview of society guidelines, legislative requirements, objective measures of outcomes, and transport practice standards occurred in work groups assessing definitions and foundations of interfacility transport, transport team composition, and transport specific considerations. Qualitative analysis was performed to characterize current science regarding interfacility transport.Data synthesisThe Task Force conducted an integrative review of 496 manuscripts combined with 120 from the authors' collections including nonpeer reviewed publications. After title and abstract screening, 40 underwent full-text review, of which 21 remained for qualitative synthesis.ConclusionsSince 2004, there have been numerous advances in critical care interfacility transport. Clinical deterioration may be mitigated by appropriate patient selection, pretransport optimization, and transport by a well-resourced team and vehicle. There remains a dearth of high-quality controlled studies, but notable advances in monitoring, en route management, transport modality (air vs ground), as well as team composition and training serve as foundations for future inquiry. Guidance from professional organizations remains uncoupled from enforceable regulations, impeding standardization of transport program quality assessment and verification.

Patients who present with atrial fibrillation (AF) or flutter with rapid ventricular response (RVR) and hemodynamic stability may be managed with either an intravenous (IV) nondihydropyridine calcium channel blocker (CCB) or a beta-blocker (BB). Patients without improved heart rates may need to switch to, or add, a second AV nodal blocker.To evaluate the incidence of rate control achievement and bradycardia in patients in AF or atrial flutter with RVR who receive both an intravenous CCB and a BB.A retrospective chart review of patients who received concomitant intravenous CCB or BB for the treatment of rapid AF or atrial flutter from April 2016 through July 2018 in the emergency department. Patients were excluded if the second agent was ordered but not administered, or if they received IV amiodarone or digoxin.A total of 136 patients were included in the analysis, and of those, 46% (n = 62) of patients achieved a heart rate110 bpm without bradycardia, and 3.7% (n = 5) developed bradycardia. Age, initial heart rate, time between CCB and BB administration, addition of an oral CCB or BB administration, or administration of IV magnesium did not impact target heart rate achievement.Adding a second nodal blocker in patients who did not achieve rate control with the first agent resulted in heart rate control 46% of the time. The development of symptomatic bradycardia was uncommon.

To determine the incidence of peri-intubation cardiac arrest through analysis of a multi-center Emergency Department (ED) airway registry and to report associated clinical characteristics.This is a secondary analysis of prospectively collected data (National Emergency Airway Registry) comprising ED endotracheal intubations (ETIs) of subjects14 years old from 2016 to 2018. We excluded those with cardiac arrest prior to intubation. The primary outcome was peri-intubation cardiac arrest. Multivariable logistic regression generated adjusted odds ratios (aOR) of variables associated with this outcome, controlling for clinical features, difficult airway characteristics, and ETI modality.Of 15,776 subjects who met selection criteria, 157 (1.0%, 95% CI 0.9-1.2%) experienced peri-intubation cardiac arrest. Pre-intubation systolic blood pressure100 mm Hg (aOR 6.2, 95% CI 2.5-8.5), pre-intubation oxygen saturation90% (aOR 3.1, 95% CI 2.0-4.8), and clinician-reported need for immediate intubation without time for full preparation (aOR 1.8, 95% CI, 1.2-2.7) were associated with higher likelihood of peri-intubation cardiac arrest. The association between pre-intubation shock and cardiac arrest persisted in additional modeling stratified by ETI indication, induction agent, and oxygenation status.Peri-intubation cardiac arrest for patients undergoing ETI in the ED is rare. Higher likelihood of arrest occurs in patients with pre-intubation shock or hypoxemia. Prospective trials are necessary to determine whether a protocol to optimize pre-intubation haemodynamics and oxygenation mitigates the risk of peri-intubation cardiac arrest.

Purpose: Critical care transport is associated with a high rate of adverse events, and the risks and outcomes of transporting critically ill patients during the COVID-19 pandemic have not been previously described. Materials and Methods: We performed a retrospective review of transports of subjects with suspected or confirmed COVID-19 from sending hospitals to tertiary care hospitals in Boston. Follow-up data were obtained for patients transported between March 1st and April 20th, 2020. Results: Of 254 charts identified, 250 patients were transported. Nine patients (3.5%) had cardiac arrest prior to transport. Twenty-nine (11.6%) had hypotension, 22 (8.8%) had a critical desaturation, and 4 (1.6%) had both en route. Hospital follow-up data were available for 189 patients. Of those intubated during their hospitalization, 44 (25.0%) had died, 59 (33.5%) had been extubated, and 13 (17.6%) had been discharged alive. For the subgroup with prior cardiac arrest, follow-up data available for 6. Of these 6, 2 died and 4 (66.7%) have been discharged alive. Conclusions: Few patients with COVID-19 had an adverse event in transport. The in-hospital mortality rate was 25%, with a 33.5% extubation rate. Patients resuscitated from cardiac arrest prior to transport had a 66.7% discharge rate among those transported to consortium hospitals.

Sepsis is a significant public health crisis in the United States, contributing to 50% of inpatient hospital deaths. Given its dramatic health effects and implications in the setting of new CMS care guidelines, ED leaders have renewed focus on appropriate and timely sepsis care, including timely administration of antibiotics in patients at risk for sepsis. Modeling the success of multidisciplinary bedside huddles in improving compliance with appropriate care in other healthcare settings, a Sepsis Huddle was implemented in a large, academic ED, with the goal of driving compliance with standardized sepsis care as described in the CMS SEP-1 measure. A retrospective cohort analysis was performed, with the primary finding that utilization of the Sepsis Huddle resulted in antibiotics being administered on average 41 min sooner than when the Sepsis Huddle was not performed. Given that literature suggests that early administration of appropriate antibiotic therapy is a major driver of mortality reduction in patients with sepsis, this study represents a proof of concept that utilization of a Sepsis Huddle may serve to improve outcomes among ED patients at risk for sepsis.

Objectives Pulmonary hypertension (PH) patients represent a complex subset of patients in the emergency department (ED), yet little is known about their presentations and outcomes. The objective of this study is to analyze the demographics, dispositions and the rates of return visits for PH patients visiting the ED, focusing on PH patients identified as having high frequency visits. Methods We performed a retrospective cohort analysis of all patients with ICD-9-CM and ICD-10-CM codes corresponding to PH presenting to an academic medical center emergency department during a 21-month period. The primary outcome was patients with high frequency ED visits, defined as 4 or more visits in a 12-month period. Secondary outcomes included ED dispositions, return ED visits, hospital length of stay, and in-hospital mortality. Results Six hundred and eighty four unique patients with a coded diagnosis of PH visited the emergency department a total of 1447 times. Eighty-four patients (12.28%) were identified as having high frequency visits. Factors associated with high frequency ED visits included male sex, liver disease, rheumatologic disease, and having Group 1 PH. PH patients’ admission rate was substantial at 56.60%, and their inpatient mortality was increased (6.7% vs 3.7% for all admissions from ED, P Conclusion PH patients in this study had frequent return ED visits, as well as elevated admission and readmission rates. Factors associated with high frequency ED visits included male sex, liver disease, rheumatologic disease, and Group 1 PH. PH patients also had increased mortality rates compared to the general ED population.

Background:Extracorporeal membrane oxygenation (ECMO) has accelerated rapidly for patients in severe cardiac or respiratory failure. As a result, ECMO networks are being developed across the world using a “hub and spoke” model. Current guidelines call for all patients transported on ECMO to be accompanied by a physician during transport. However, as ECMO centers and networks grow, the increasing number of transports will be limited by this mandate.Objectives:The aim of this study was to compare rates of adverse events occurring during transport of ECMO patients with and without an additional clinician, defined as a physician, nurse practitioner (NP), or physician assistant (PA).Methods:This is a retrospective cohort study of all adults transported while cannulated on ECMO from 2011-2018 via ground and air between 21 hospitals in the northeastern United States, comparing transports with and without additional clinicians. The primary outcome was the rate of major adverse events, and the secondary outcome was minor adverse events.Results:Over the seven-year study period, 93 patients on ECMO were transported. Twenty-three transports (24.7%) were accompanied by a physician or other additional clinician. Major adverse events occurred in 21.5% of all transports. There was no difference in the total rate of major adverse events between accompanied and unaccompanied transports (P = .91). Multivariate analysis did not demonstrate any parameter as being predictive of major adverse events.Conclusions:In a retrospective cohort study of transports of ECMO patients, there was no association between the overall rate of major adverse events in transport and the accompaniment of an additional clinician. No variables were associated with major adverse events in either cohort.

With the COVID-19 pandemic, healthcare systems have been facing an unprecedented, large-scale respiratory disaster. Prone positioning improves mortality in severe hypoxemic respiratory failure, including COVID-19. While this is effective for intubated patients with moderate-to-severe ARDS, it has also been shown to be beneficial for non-intubated patients. Critical care transport (CCT) has become an essential component of combating COVID-19, frequently transporting patients to receive advanced respiratory therapies and distribute patients in concert with available resources. With increasing awake proning, CCT teams may encounter patients supported in the prone position. Historically, transporting in the prone position has not been embraced due to substantial risks of desaturation during transport. In this case report, we describe the first known report of transporting a non-intubated, critically ill COVID-19 patient in the prone position.

Hypoxemic patients often desaturate further with movement and transport. While inhaled epoprostenol does not improve mortality, improving oxygenation allows for transport of severely hypoxemic patients to tertiary care centers with a related improvement in mortality rates. Extracorporeal membrane oxygenation (ECMO) use is increasing in frequency for patients with refractory hypoxemia, and with increasing regionalization of care, safe transport of hypoxemic patients only becomes more important. In this series, four cases are presented of young patients with severe hypoxemic respiratory failure from Legionnaires’ disease transported on inhaled epoprostenol to ECMO centers for consideration of cannulation. With continued climate changes, Legionella and other pathogens are likely to be a continued threat. As such, optimizing oxygenation to allow for transport should continue to be a priority for critical care transport (CCT) services.

Research has shown that do not resuscitate (DNR) and do not intubate (DNI) orders may be construed by physicians to be more restrictive than intended by patients. Previous studies of physicians found that DNR/DNI orders are associated with being less willing to provide invasive care.The purpose of this study was to assess the influence of code status on emergency residents' decision-making regarding offering invasive procedures for those patients with DNR/DNI compared with their full code counterparts.We conducted a nationwide survey of emergency medicine residents using an instrument of 4 clinical vignettes involving patients with serious illnesses. Two versions of the survey, survey A and survey B, alternated the DNR/DNI and full code status for the vignettes. Residency leaders were contacted in August 2018 to distribute the survey to their residents.Three hundred and three residents responded from across the country. The code status was strongly associated with decisions to intubate or perform CPR and influenced the willingness to offer other invasive procedures. DNR/DNI status was associated with less frequent willingness to place central venous catheters (88.2% for DNR/DNI vs. 97.2% for full code, p 0.001), admit patients to the intensive care unit (89.9% vs. 99.0%, p 0.001), offer dialysis (79.3% vs. 98.0%, p 0.001), and surgical consultation (78.7% vs. 94.2%, p 0.001).In a nationwide survey, emergency medicine residents were less willing to provide invasive procedures for patients with DNR/DNI status, including the placement of central venous catheters, admission to the intensive care unit, and consultation for dialysis and surgery.

Interpreting ventilator screens may be intimidating for beginners, but the data are actually fairly simple despite being presented slightly differently on the screens of each mechanical ventilator brand. There are a few key points to remember when reviewing ventilator screens. (1) The values set by clinicians are found on the bottom of the screen. The patient’s response is located at the top of the screen. (2) Data are provided in both numerical and graphical contexts on the screen. (3) Ventilators provide three types of tracings: flow, pressure, and volume. All values are readily labeled directly on the ventilator screens.

Acute respiratory distress syndrome, (ARDS) is a condition of diffuse alveolar damage and inflammation, secondary to numerous possible etiologies. Few interventions in critical care have been as reproducibly beneficial to patients as low tidal volume ventilation. Prevention of ventilator-induced lung injury is a key benefit of active ventilator management in the ED. In ARDS, as well as other patients, maintaining a plateau pressure of less than 30cmH2O is essential to preventing ventilator-induced lung injury. Recruitment maneuvers, neuromuscular blockade, and prone positioning should be used for persistent or severe hypoxemia. Inhaled pulmonary vasodilators can improve oxygenation, and ECMO should be considered for severe ARDS.

Many terms are used interchangeably in mechanical ventilation, and this leads to confusion. Select appropriate terms, and use them consistently. Key concepts include tidal volume, respiratory rate, minute ventilation, PEEP, resistance, compliance, peak inspiratory pressure, plateau pressure, autoPEEP, and derecruitment. Modes of ventilation are assist control (including volume control and pressure control, as well as pressure-regulated volume control), pressure support, and synchronized intermittent mandatory ventilation. Tidal volume should be selected for 6–8 mL/kg of predicted body weight, based upon height and sex. The respiratory rate should be selected to target a reasonable minute ventilation. PEEP should be set at minimum of 5 cmH2O, and titrated higher as needed to correct for hypoxemia and derecruitment. Once the ventilator settings are selected the patient must be continuously reassessed, settings such be titrated based on ABG results, and peak inspiratory pressures and plateau pressures monitored to reduce harm. Patients with acute respiratory distress syndrome (ARDS), asthma, COPD, and neurologic injury are especially vulnerable populations of ventilated patients who require additional attention and careful ventilator management. While mechanically ventilated patients are among the most critically ill patients cared for in the ED, appropriate, evidence-based care can positively impact the patients’ trajectories and improve outcomes.

The ventilator mode refers to the way the ventilator interacts with the patient. Assist control (AC) is one of the most commonly used modes of ventilation, set to either target a desired pressure or volume. Pressure support ventilation is a partially supported, or spontaneous, pressure-controlled mode of ventilation with no set respiratory rate or tidal volume. The peak inspiratory pressure (PIP) represents pressures in the entire airway system and is a measure of both the resistance and compliance. The plateau pressure (Pplat), which is measured during an inspiratory hold, is the reflection of the pressure delivered to the alveoli and the compliance of the system. When air is trapped in the alveoli at the end of exhalation, it exerts a pressure above and beyond the set PEEP. This pressure can actually be quantified on the ventilator by pressing the expiratory pause button and is known as AutoPEEP or intrinsic PEEP (iPEEP).

A discussion of the principles of mechanical ventilation must begin with a review of important physiologic concepts. This chapter is a review of gas exchange, focusing on oxygenation and ventilation. There are five major causes of hypoxemia: V/Q mismatch, shunt, alveolar hypoventilation, decreased partial pressure of oxygen, and decreased diffusion. Several other key principles of hypoxemia include understanding hypoxemic vasoconstriction and derecruitment. Resistance and compliance are core concepts in respiratory physiology and are important in caring for ventilated patients. Monitoring for air trapping is essential to preventing untoward outcomes as well.

PURPOSE Given that the benefits of helicopter transport vary with geography and healthcare systems, we assessed transport times for rotor wing versus ground transport over a 10 year period in an urban setting. MATERIALS AND METHODS All completed transports from 153 sending hospitals in New England from 2009 through 2018 to 8 local tertiary care centers were extracted from an administrative database. The primary outcome of interest was patient loaded transport time for rotor wing versus ground transports. Overall, 25,483 patient transports met the inclusion criteria and were included in this study. We assessed patient loaded transport time for all transports, and determined mean time to arrive at the scene, scene to patient time, the bedside time, and distance at which the patient-loaded transport time was faster for rotor wing than for ground transport. We also performed subgroup analyses, evaluating transport times by time of day, day of the week, and destination. RESULTS The most common indication for transport was adult trauma, (n = 6,008, 23.6%) followed by adult cardiac (n = 4359, 17.1%), adult neuro (3729 14.6%), and adult medical (n = 3691, 14.5%). The median miles traveled for all transports was 26.0, IQR 14-38, ranging from 1 to 264 miles. The median patient-loaded transport time was 27 min (IQR 15-40) for all transports. Nearly all time intervals were shorter for rotor wing versus ground transports, and patient-loaded transport time was significantly shorter at 15 minutes compared to 38 minutes (IQR 12-22 vs 28-33, P < 0.001). There was no distance at which the patient-loaded transport time was faster for ground transport than for rotor wing. CONCLUSIONS In over 25,000 transports over 10 years, in a compact metropolitan area with relatively short transport distances and times, the use of the helicopter was associated with substantial time savings.

Dr. Patrick Lowe: Our case today is that of a 47-year-old woman who was referred to our emergency department (ED) due to bloody urine, dark tarry stools, red spots on her skin, and bruising throughout her body. Fourteen days prior to presentation, she began exhibiting intermittent fevers, headache, shortness of breath, and a dry cough, and she tested positive for SARS-CoV-2 (the virus that causes COVID-19 pneumonia). Over the 3 days prior to her ED presentation, she experienced a headache that was more intense than the headaches she had been having in the preceding 2 weeks. She reported episodes of both dark urine as well as bright red blood in her urine. In addition, she had multiple dark stools described as tar-like when asked. On the day of her ED presentation, the patient noted a red rash throughout her body. In addition, earlier in the day, she had atraumatic self-limited epistaxis. She denied any falls or head strikes, vision changes, focal weakness or numbness, shortness of breath, chest pain, abdominal pain, or peripheral swelling.

Although cardiogenic shock is uncommon in the emergency department, it is associated with high mortality. Most cardiogenic shock is caused by ischemia, but nonischemic etiologies are essential to recognize. Clinicians should optimize preload, contractility, and afterload. Volume-responsive patients should be resuscitated in small aliquots, although some patients may require diuresis to improve cardiac output. Vasopressors are important to restore end-organ perfusion, and inotropes improve contractility. Intubation and positive pressure ventilation impact hemodynamics, which, depending on volume status, may be beneficial or deleterious. Knowing indications for mechanical circulatory support is important for timely consultation or transfer as indicated.

Purpose Evaluate the association between chronic right ventricle (RV) dysfunction by transthoracic echocardiogram (TTE) and outcomes in patients with acute pulmonary embolism (PE). Methods This was a retrospective analysis of TTE findings in acute PEs. TTEs were used to classify the presence of chronic right ventricular pressure overload (RPVO), defined as RV hypertrophy or RV systolic pressure (RVSP) >50 mmHg, acute RVPO, defined as RV dysfunction not meeting the chronic RVPO definition, or no RV dysfunction. The primary outcome was a composite of death or need for advanced PE therapies at 7 days. Results Of 466 patients, 288 had evidence of RV dysfunction. Thirty percent (140) had evidence of chronic RVPO and 148 patients had evidence of acute RVPO. Chronic RVPO patients were older (P = .004), more likely to have COPD, and had lower heart rates and troponin-t values. The acute RVPO patients included more women and were less likely to have a prior PE. There was no difference in outcomes between the acute and chronic RVPO cohorts. Conclusions Chronic RVPO patients had lower heart rates and troponin-t values. Despite these differences there were no differences in need for advanced therapeutic interventions or 7 day mortality.

In the United States, physicians finishing residency or fellowship training or who are at different stages of their careers frequently take academic positions in medical centers in different states. Despite the frequency with which students move among states, there is a paucity of guidance in the literature regarding best practices for minimizing the disruptions and challenges associated with moving to a new position in a new state. In this article, we review the available peer-reviewed and non-peer-reviewed literature to provide specific guidance for physicians and healthcare professionals transitioning to a new position in a different state., Moving from one state to another for a new position or opportunity is a common event for academic physicians. Although moving can be personally and professionally disruptive for everyone, it can be particularly challenging for academic physicians. From practical considerations such as applying for a new state medical license to professional challenges such as minimizing disruption to educational or research projects, there are numerous challenges associated with relocating to an academic institution in a new state. Despite the frequency with which academic physicians move between institutions in different states, we could not identify any practical guidance about moving in the literature. We searched the peer-reviewed literature, reviewed non-peer-reviewed open access sources, and drew from our own experience as academic physicians who have recently moved, and collated pertinent resources to develop a guide of what physicians need to consider when planning a move to a new position in a new state. Our review and guidance considers the following issues: state licensing, governmental certification, maintaining communication with collaborators and colleagues, working with institutional review boards regarding ongoing research projects, transferring funds from grants, transitioning out of clinical practice, and transferring data and resources. Anticipating the requirements and challenges of moving can help academic physicians, whether at the beginning, middle, or end of their careers, with the process of moving to a new state for a new position.

Background Hydrochlorothiazide (HCTZ) is a commonly prescribed sulfonamide thiazide-type diuretic medication that has been associated with rare cases of noncardiogenic pulmonary edema. Case Report A man in his 50s with a medical history notable for hypertension was transferred to our institution for evaluation of refractory hypoxemia. After taking an initial dose of HCTZ earlier in the day, he developed progressive respiratory failure and was intubated at a referring hospital. Progressive hypoxemia and acute respiratory distress syndrome (ARDS) developed and he was transferred to our institution for extracorporeal membrane oxygenation (ECMO). Venovenous ECMO (vv-ECMO) was initiated in the Emergency Department and he was admitted to the intensive care unit. After several days of ECMO, his ARDS resolved and he was decannulated and extubated. Further history indicated that he had had two previous episodes of ARDS in the setting of HCTZ use without recognition of the inciting trigger, likely explaining his presentation. Why Should an Emergency Physician Be Aware of This? One of the most commonly prescribed antihypertensives, HCTZ is associated with rare cases of pulmonary edema, which typically develop within minutes to hours of the initial dose of the medication. Although most cases resolve with supportive care, severe cases may require intubation and even vv-ECMO. The mechanism of the reaction is unknown, and affected individuals are typically able to tolerate other sulfonamide medications without issue.

Background: Little is known about historical and recent application trends for pulmonary critical care medicine (PCCM) or pulmonary medicine (PM) fellowship programs. Describing trends in and characteristics of PCCM and PM applications, applicants, and fellowship programs can help program directors and medical educators understand trainees’ interest in and application patterns for these fellowship programs. Objective: The objective of this study was to use National Residency Match Program data to assess recent trends in PCCM and PM fellowship applications and compare characteristics of applicants and fellowship programs. Methods: In 2019, we used National Residency Match Program data to evaluate applicant ranking and matching in PCCM and PM fellowship programs and to compare applicant and fellowship program characteristics. Results: From 2008 through 2019, the majority of applicants (59.1%) matched into PCCM were graduates of U.S. allopathic or osteopathic medical schools, whereas 87% of PM fellows were non-U.S. graduates. PCCM was the preferred specialty for 90.8% of matched applicants versus only 31.6% of matched PM applicants (P

Background While emergency physicians are familiar with the management of hypoxemic respiratory failure, management of mechanical ventilation and advanced therapies for oxygenation in the emergency department have become essential during the coronavirus disease 2019 (COVID-19) pandemic. Objective We review the current evidence on hypoxemia in COVID-19 and place it in the context of known evidence-based management of hypoxemic respiratory failure in the emergency department. Discussion COVID-19 causes mortality primarily through the development of acute respiratory distress syndrome (ARDS), with hypoxemia arising from shunt, a mismatch of ventilation and perfusion. Management of patients developing ARDS should focus on mitigating derecruitment and avoiding volutrauma or barotrauma. Conclusions High flow nasal cannula and noninvasive positive pressure ventilation have a more limited role in COVID-19 because of the risk of aerosolization and minimal benefit in severe cases, but can be considered. Stable patients who can tolerate repositioning should be placed in a prone position while awake. Once intubated, patients should be managed with ventilation strategies appropriate for ARDS, including targeting lung-protective volumes and low pressures. Increasing positive end-expiratory pressure can be beneficial. Inhaled pulmonary vasodilators do not decrease mortality but may be given to improve refractory hypoxemia. Prone positioning of intubated patients is associated with a mortality reduction in ARDS and can be considered for patients with persistent hypoxemia. Neuromuscular blockade should also be administered in patients who remain dyssynchronous with the ventilator despite adequate sedation. Finally, patients with refractory severe hypoxemic respiratory failure in COVID-19 should be considered for venovenous extracorporeal membrane oxygenation.

In the prehospital setting, the use of ambulance lights and sirens (LS) has been found to result in minor decreases in transport times, but has not been studied in interfacility transportation.The objective of this study was to evaluate the indications for LS and the impact of LS on transport times in interfacility critical care transport.We performed a retrospective analysis using administrative data from a large, urban critical care transportation organization. The indications for LS were assessed and the transport times with and without LS were compared using distance matching for common transport routes. Median times were compared for temporal subgroups.LS were used in 7.3% of transports and were most strongly associated with transport directly to the operating room (odds ratio 15.8; 95% confidence interval 6.32-39.50; p 0.001). The timing of the transport was not associated with LS use. For all transports, there was a significant decrease in the transport time using LS, with a median of 8 min saved, corresponding to 19.5% of the overall transportation time without LS (33 vs. 41 min; p 0.001). The reduction in transport times was consistent across all temporal subgroups, with a greater time reduction during rush hour transports.The use of LS during interfacility critical care transport was associated with a statistically significant time reduction in this urban, single-system retrospective analysis. Although the use of LS was not associated with rush-hour transports, the greatest time reduction was associated with LS transport during these hours.