Dr. Rickman is a Interventional Pulmonologist at Vanderbilt University Medical Center his clinical expertise lies primarily in interventional pulmonology and thoracic oncology. He is trained and performs the full spectrum of diagnostic, therapeutic and palliative airway procedures for patients with lung cancer or suspected lung cancer. This extends from smoking cessation counseling, early detection with endoscopic treatment all the way to palliative airway procedures to alleviate symptoms of the patient with advanced lung cancer.
Opinions expressed in this blog are mine and not necessarily those of VUMC.
TwitterLinkedInSearch
Small bore Catheter and TPA for loculated effusions
My protocol for loculated effusions (malignant or infected) drained with small bore tubes is based on the attached article.
---------------------------------
Contraindications
No systemic levels of anticoagulation. (Prophylactic heparin, LMWH and asprin are OK)
Protocol
TPA dose: 6mg in 60ml of 0.9% saline
1 cycle of TPA = 3 days
Day 1: Instill TPA, stop suction clamp tube (by turning stopcock off) for 1 hour, resume suction
Day 2: Repeat
Day 3: Repeat
Day 4: Repeat Noncontrast CT chest to check for resolution
ABC's of Critical Care
Course Summary
This tool was developed to help learners remember the most important important articles in critical care. There are many examples of mnemonic devices being used in medicine to help approach complex problems or memorize many details. Common examples are MUDPILES: causes of metabolic acidosis, ABCDE: Primary survey in trauma, CABIGK: treatment of hyperkalemia. We propose that this mnemonic device can be used to organize and focus the chaos of caring for criticically ill patients. The idea was conceived by Emir Festic, MD after seeing a email sent by Otis Rickman, DO to housestaff of useful articles in critical care.
A B C D E F G H
A RDS A low tidal volume mechanical ventilation strategy is now the standard of care in ARDS. The evidence for this comes from a article published by the ARDS network. They demonstrated a significant mortality reduction (40% to 31%) when the Vt was set at 6cc/kg, plateau pressure was kept <28. They also used a higher respiratory rate around 20 and a PEEP of 10.
The Acute Respiratory Distress Syndorme Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000; 342:1301-1308.
B lood transfusions The use of blood products in the ICU is quite controversial. The best evidence suggests witholding transfusions unless Hgb is <7 for relatively stable patients and if there is active ischemia then the threshold in <10. Overall, 30-day mortality was similar between the restrictive and liberal groups (18.7 percent vs. 23.3 percent, P= 0.11). However, the mortality rates were significantly lower with the restrictive transfusion strategy among patients who were less acutely ill -- those with an Acute Physiology and Chronic Health Evaluation II score of < or =20 (8.7 percent in the restrictive-strategy group and 16.1 percent in the liberal-strategy group; P=0.03) -- and among patients who were less than 55 years of age (5.7 percent and 13.0 percent, respectively; P=0.02), but not among patients with clinically significant cardiac disease (20.5 percent and 22.9 percent, respectively; P=0.69). The mortality rate during hospitalization was significantly lower in the restrictive-strategy group (22.3 percent vs. 28.1 percent, P=0.05).
Hebert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G, Tweeddale M, Schweitzer I, Yetisir E. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group." N Engl J Med. 1999 Feb 11;340(6):409-17.
C orticosteroids Hydorcortisone and fludrocortisone improve survival in patients with septic shock. To implement this first obtain a ACTH stim test using 250mcg of cosyntropin and immediately start hydrocortisone 50mg IV q6h and fludrocortisone 50mcg PO qd. If the cortisol increases by <9 on the stim test then the patient is a nonresponder and treatment is continued for 7 days otherwise stop the steroids. The study by Annane resulted in a significant decrease in 28day mortality and reduction in the duration vasopressor therapy. In other words 1 additional life is saved with steroids per 7 treated.
Annane D, Sebille V, Charpentier C, Bollaert PE, Francois B, et a. Effect of treatment with low doses of hydrocortisone and hydrocortisone on mortality in patients with septic shock. JAMA 2002 Aug 21;288(7):862-71
D rotrecogin alfa Drotecogin alpha (Xigris) aka activated protein C (APC) is the hot drug in sepsis currently. Bernard gave septic patients APC 24mcg/kg/hr x 96 hours. There was a significant reduction in mortality, a RRR of death by 20% and a ARR of death by 6.1%. There was higher incidence of serious bleeding in the APC group 3.5% vs 2%.
Bernard GR, Vincent JL, Laterre PF, et al. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med 2001; 344:699-709.
E arly goal directed fluid therapy Fluid, fluid and more fluid. Rivers randomized septic shock patients to standard or early goal directed therapy. This study (done in ER in Detroit so it was slightly different population patients) gave a 500-ml bolus of crystalloid every 30 minutes to achieve a CVP of 8 to 12. If the MAP was less than 65 mm Hg after the bolus then vasopressors were given to maintain a MAP >65. The average amount of fluid given in the first 6 hours was 5 liters. This significantly reduced hospital mortality from 46% to 30%. Interestingly there was no difference in the 3 day period of the total amount of fluid given (ie the standard therapy ended up getting the same amount of fluid later with a worse outcome).
Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M: Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345:1368-77.
F amotidine Stress ulcer prophylaxis is required in mechanically ventilated patients. H2 blockers and sucralfate have both been shown to be effective in this patient population. Due to issues with medication binding and difficulty of administration, sucralfate is not the prefered agent. The point here is that prophylaxis shoud be started in mechanically ventilated patients. Head injury and burn patients also benefit from stress ulcer prophylaxis.
Cook D, Heyland D, Griffith L, Cook R, Marshall J, Pagliarello J. Risk factors for clinically important upper gastrointestinal bleeding in patients requiring mechanical ventilation. Canadian Critical Care Trials Group.Crit Care Med. 1999 Dec;27(12):2812-7.
G lucose control This may be the most important thing you can do for your patients. van den Berghe looked at ~1500 patients in a SICU. By keeping glucose between 80 and 110 with a insulin drip they significantly reduced mortality from 8% to 4% and in folks who stayed longer than 5days from 20% to 10%. They also reduced the following: Overall hospital mortality reduced by 34%, Boodstream infections by 41%, Transfusions by 50%, Acute renal failure by 41%
van den Berghe G, Wouters P, Weekers F, et al. Outcome benefit of intensive insulin therapy in the critically ill: Insulin dose versus glycemic control. Crit Care Med. 2003 Feb;31(2):359-66
Approach to the Critically Ill Unstable patient
This is a lecture I give to critical care fellows and resident to help guide them when caring for the critically ill
Understanding
By Otis B. Rickman, D.O.
Prologue
“Help me understand”, she said. She was a delightful silver haired matriarch of a large family. I was seeing her in consultation for a pulmonary nodule in the Vanderbilt Ingram Cancer Center Pulmonary Oncology Clinic on a crisp afternoon in the spring of 2010. What she wanted to “understand” was why she had this spot on her lung, what it could be and what could be done about it. As I had done thousands of times before, I launched into my spiel about pulmonary nodules: where they come from, what they could be and what to do about it. In her case the most appropriate next step was to perform bronchoscopy and obtain a biopsy.
The word bronchcoscopy derives from the greek brongchos “conduits to the lungs” and skopos “to aim or target”. A physician using a bronchoscope performs bronchoscopy. A bronchoscope is a long flexible instrument (about the diameter of a coaxial cable that plugs into the back of your TV) with a light and a camera on the end that captures an image and displays it on a video monitor. (Fig 1) The current standard of care for sedation is to give medicine in the IV to create a calm and relaxed state and apply topical anesthetic (numbing medicine like at the dentist) to the mouth and nose to abolish both cough and gag reflexes. The bronchoscope is then introduced into either the mouth or the nose, advanced past the voice box and into the bronchial tubes of the lungs, where it can then be advanced into each lobe of lung and to lesions for biopsies.
“Does it hurt”, she said. “No, there are no pain fibers in the lung. It is an outpatient procedure and you can go home the same day”, I explained. “It’s a piece of cake”, I stated glibly. Her demeanor changed. “Piece of cake! Have you ever had it done? How dare you say that it is a piece of cake”, she scolded me. I apologized, scheduled her for the bronchoscopy the next day and went on to the next patient.
However, that conversation kept coming back and occupying my thoughts. I ruminated about it during my daily commute, at work and as I lay awake in bed prior to falling asleep. I finally figured out the reason it kept coming up. It was because she was right; I had no idea what it was like to have a bronchoscopy. I was a hypocrite! Even more, I had no idea what it was like to be a patient. Thankfully, I have never been hospitalized, never had surgery or a procedure. Not even a broken bone! I was completely ignorant of the entire medical process from the patient viewpoint.
It is taught early on in medical school, that empathy is and essential attribute of good physicians. The concept of empathy is that through imagination, rather than literally, the physician experiences what the patient is going through. At this point, I felt that empathy was no longer good enough; I needed to have a bronchoscopy! A plot began to formulate in my mind, but I would need collaborators to carry it out.
Soon after moving to Nashville in the fall of 2009, I was approached by my colleague Dr. M, to participate as a co-investigator in a research project for which the primary aim was to develop an early detection test for lung cancer, which I agreed to do. He also asked me to perform a bronchoscopy on him as part of his research study, which I also agreed to do, but hadn’t done yet. These two thoughts came together. To accomplish my goal of understanding what it was like to have a bronchoscopy, I needed to volunteer for Pierre’s research study. So I signed up to have a bronchoscopy as a normal control for this study. Everyone thought I was nuts: my wife, colleagues, fellows and nurses. But I was resolved to carry this out.
I was uneasy on the morning of March 25, 2010 as I rode the elevator up to Vanderbilt’s Clinical Research Center. It’s not to late to walk away, I kept thinking. I must say it was quite surreal to walk into the procedure room and not go to the head of the bed but to lie down on it, take my shirt off, get an IV started, have ECG and BP monitors attached and be placed on oxygen. It hit home at that point. I am going to allow these people to invade my personal space and give up autonomy! This was the most important lesson I learned that day, I would be completely at the mercy of someone else. The research nurse looked at me concernedly and asked, “Are you sure you don’t want IV sedation?” I told her, “No”. The reason I refused IV sedation was not male bravado, but that not only did I want to experience bronchoscopy; I wanted to remember every detail. In most cases a desirable side effect of medications used for procedural sedation is amnesia. In my case, if I used IV sedation there was a good chance I wouldn’t be able to recall the procedure and I would not be able to recall the experience of bronchoscopy and hence be unable to explain to my patients what to expect and really prepare them for bronchoscopy. Dr. M began the important process of topical anesthetic application. In a sitting position, I first gargled lidocaine that was very bitter, then had topical benzocaine sprayed on the back of my throat. The benzocaine smelled like bananas, but I soon realized it tasted like bananas that had been through the monkey! I could no longer feel the back of my throat, which made it difficult to swallow my saliva. What had I gotten myself in to! I was asked to lie down, a washcloth was placed over my eyes and viscous lidocaine was place into my right nostril to numb it.
With the Yankuer suction in my left hand to clear secretions (like at the dentist) we were underway! I was having a bronchoscopy. Dr. M inserted the scope in my nostril I felt nothing. He advanced it to my voice box I felt nothing. Diana from the musical “A Chorus Line” popped into my head. He warned me as he applied lidocaine to my voice box that it might make me cough, I then felt a cold sensation, it didn’t hurt and wasn’t unpleasant but did cause a cough that quickly went away. This process repeated several times until my entire bronchial tree was numb. I must say it was bizarre to hear him request instruments and supplies to perform washings, brushings and biopsies of MY lungs and not feel a thing. All in all it took 22 minutes. Thirty minutes later I was in the bronchoscopy suite performing a bronchoscopy on a patient with a new sense of awe and admiration for my patients and new respect for the privileges they allow me.
This article is dedicated to that delightful patient who afforded me this opportunity, for which I am eternally grateful. The nodule turned out to be an early stage lung cancer. She underwent surgery and had a portion of her lung removed and has likely been cured of her disease.
Epilogue
Since my bronchoscopy, Dr. M, my nurse Charla Atkins, 3 pulmonary fellows 2 residents and 2 pulmonary/ICU nurses I work with have all volunteered for the research study and undergone a bronchoscopy.
The Physician's Oath
Variations of this oath are taken at the time of being admitted as a member of the medical profession. Variations are the Physician's Oath, Hippocratic Oath, and Osteopathic Oath. The themes are the same in all.
- I solemnly pledge myself to consecrate my life to the service of humanity;
- I will give to my teachers the respect and gratitude which is their due;
- I will practise my profession with conscience and dignity; the health of my patient will be my first consideration;
- I will maintain by all the means in my power, the honour and the noble traditions of the medical profession; my colleagues will be my brothers;
- I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient;
- I will maintain the utmost respect for human life from the time of conception, even under threat, I will not use my medical knowledge contrary to the laws of humanity;
- I make these promises solemnly, freely and upon my honour
Bronchial Thermoplasty (RFA) for Severe Refractory Asthma
The procedure, called bronchial thermoplasty, involves the delivery of radio frequency energy to the airway wall, which heats the tissue up to about 65°C, high enough to reduce airway smooth muscle mass, but low enough to avoid tissue destruction and scarring. Airway smooth muscle hypertrophy is presumably the culprit in airway bronchoconstriction in severe asthmatics that results in difficulty breathing, coughing spasms and wheezing. The RF energy is delivered via a catheter developed by the Asthmatx Corporation that emits radio waves, similar to microwaves used to cook food.
The FDA approved the device for patients 18 and older who cannot adequately control their asthma with prescription medications. While roughly 20 million people in the U.S. suffer from asthma, thermoplasty would only be appropriate for about 2 million adults with severe asthma who don't get relief from existing drugs.The FDA approved the technology under the condition that Asthmatx track patients for five years to monitor their long-term health.
FISHing out lung cancer
In the March 1 issue of the American Journal of Respiratory and Critical Care Medicine, they report that FISH was able to detect an additional 32 percent of lung cancers that were missed by routine cytology. FISH was especially useful for peripheral nodules, detecting an additional 28 percent (tumors greater than 2 cm) to 44 percent (tumors less than 2 cm) of lung cancers. The results suggest that, used in conjunction with routine cytology, FISH testing – which can be performed on specimens with few tumor cells present – can improve lung cancer detection, especially in peripheral lung nodules.
Small bore chest tubes with fibrinolysis are as effective as large bore tubes for treating pleural infection
iPhone, Google Calendars and Microsoft Exchange
So I have an iPhone, a Google Calendar and a Microsoft Exchange account at work. My goal was to have all of these calendars be in sync and ultimately come together on my iPhone. One phone to rule them all! (Sorry JRR).
Setup Exchange on iPhone
Following instuctions on Apple's Support page (http://bit.ly/27IPx) I contacted the help desk at my new employer and got required information, plugged them in and walla my calendar, contacts and email were on my iPhone.
Synchronize Exchange and Google
Next I installed Google Calendar Sync (http://bit.ly/X6gn) on my PC at work.
Configuring CalDAV on iPhone 3.1 for Primary and secondary Google Calendars
I finished by setting up CalDav for Google Calendar. Note that you can't use google sync, because it uses a MS Exchange protocol and only one ActiveSync account can be on the iPhone at a time. So you must use the CalDav method.
1. On the iphone go to Settings>Mail, Contacts, Calendars
2. Tap "Add account", scroll down to bottom and tap "other"
3. Then under calendars tap "Add CalDav Account"
4. Enter your google information
Server: google.com Username: [youronecoolgoogleusername]
Password: [youronecoolgooglepassword]
Description: [whateveryouwant]
5. Tap "next"
6. Now should have an account with your main google calendar
7. If you want to add in a secondary google calendar, go to Google Calendar, click "Settings" at top right of screen, Select "Calendars" tab, click on the Calendar of interest to you, scroll down to bottom and find the calendar ID
OK now the tricky part. Take this ID and plug it into this URL https://www.google.com/calendar/dav/[CalendarID]/user in place of [CalendarID]. For example:
https://www.google.com/calendar/dav/50123456LEFJOPjadlfjaj@group.calendar.google.com/user Now cut and paste that URL and email it to your iPhone. On your iPhone open that email and copy it.
Now repeat the process documented in step 4 with following changes
Description: [nameitsomethingelse]
After you have created the account, select the newly created account. Scroll down to bottom and tap Advanced Settings.
Delete the URL that is in the Account URL section and paste the URL you copied from the email.
Should be good to go!! Now I just have to figure out how to do the same with my contacts??
H1N1
Concern about the forthcoming vaccine is understandable and centers on the debacle during the 1976-77 flu season. That's when a swine flu "outbreak" (single soldier) at Fort Dix, N.J., led the federal government to remove safeguards and expedite vaccine production. About 40 million people were vaccinated, before Guillain-Barre syndrome (GBS), a rare auto-immune neurological disorder, was identified as a side effect. It is estimated that more than 500 people developed GBS and 25 people died after receiving the vaccine. In other words 0.00125% of those vaccinated got GBS. A number that is unacceptable given that there was never a flu outbreak or epidemic. Since the 1977 pandemic never materialized; there was only the risk of the vaccine. Today, the pandemic is a reality. The benefit of the vaccine far outweighs the risks. As with any treatment the risks of getting the illness must be wieghed against the risks of the treatment in this case a vaccine. The risks for this vaccine should be similar to the current seasonal flu vaccine. Because, vaccines against novel influenza A (H1N1) virus infection are being produced using methods similar to those used for seasonal influenza vaccines. Since the 1977 vaccination, influenza vaccines have not been clearly linked to GBS. However, if there is a risk of GBS from seasonal influenza vaccines, it would be no more than approximately 1 case per million persons vaccinated. To put this in perspective your risk of dying while: walking along the road in 1 in 47,273, riding in a car 1 in 17,625, riding a horse 1 in 244,180, Since the vaccine for H1N1 will not be available until the fall, protect yourself by:
- Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it. If you don't have a tissue cough into your elbow or shoulder.
- Carry a alcohol-based hand cleaner and use it all the time.Wash your hands often with soap and water, especially after you cough or sneeze.
- Avoid touching your eyes, nose or mouth.
- Stay home if you get sick. CDC recommends that you stay home from work or school and limit contact with others to keep from infecting them.
- All persons currently recommended to get the regular seasonal vaccine should get it.
- Pregnant women because they are at higher risk of complications and can potentially provide protection to infants who cannot be vaccinated;
- Household contacts and caregivers for children younger than 6 months of age because younger infants are at higher risk of influenza-related complications and cannot be vaccinated. Vaccination of those in close contact with infants less than 6 months old might help protect infants by “cocooning” them from the virus;
- Healthcare and emergency medical services personnel because infections among healthcare workers have been reported and this can be a potential source of infection for vulnerable patients. Also, increased absenteeism in this population could reduce healthcare system capacity;
- All people from 6 months through 24 years of age
- Children from 6 months through 18 years of age because we have seen many cases of novel H1N1 influenza in children and they are in close contact with each other in school and day care settings, which increases the likelihood of disease spread, and
- Young adults 19 through 24 years of age because we have seen many cases of novel H1N1 influenza in these healthy young adults and they often live, work, and study in close proximity, and they are a frequently mobile population; and,
- Persons aged 25 through 64 years who have health conditions associated with higher risk of medical complications from influenza.
- Heart disease: 631,636
- Cancer: 559,888
- Stroke (cerebrovascular diseases): 137,119
- Chronic lower respiratory diseases: 124,583
- Accidents (unintentional injuries): 121,599
- Diabetes: 72,449
- Alzheimer's disease: 72,432
- Influenza and Pneumonia: 56,326
- Nephritis, nephrotic syndrome, and nephrosis: 45,344
- Septicemia: 34,234
http://www.cdc.gov/h1n1flu/
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5834a1.htm
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr58e0821a1.htm
http://riskcomm.com/visualaids/riskscale/datasources.php
http://www.cdc.gov/nchs/fastats/deaths.htm
