InTouch 2023 Vol 12, 1

Continuing Medical Education: How CME Translates to Better Patient Care

those interested in providing better service to patients. CME sessions can take on many different forms, whether it be a one-day series of lectures focused on a particular topic or a multiple-day experience going over various topics with a number of different speakers. Regardless of the format, the goal remains the same – to provide education for physicians and other healthcare providers so that they may be the most informed and effective practitioners and educators possible. The Graduate School of Medicine offers multiple CMEs each year on a multitude of topics within the medical field. I talked with Dr. Amy Barnett, an internal medicine physician here at UTMCK, about the importance of CME and what she feels makes an effective CME session.

What do you look for when choosing CME opportunities? Is it based more off of interest or usefulness?

I look for conferences that are arranged over a period of 2-3 days involving multiple different types of CMEs. I also look for CMEs in locations where I would be interested in traveling so that when each day of the conference is finished, I can find places to explore and relax. I try to find CME opportunities that are useful to me and where I can learn up-to-date information on particular topics.

As healthcare providers, it is essential that we continue to increase our knowledge in order to provide the most up-to-date and high-quality patient care. Taking part in continuing medical education, otherwise known as CME, is one of the many ways in which we may accomplish this goal. The Accreditation Council for Continuing Medical Education, otherwise known as the ACCME, is the organization responsible for sponsoring continuing medical education. They define CME as consisting of “educational activities which serve to maintain, develop, or increase the knowledge, skills, and professional performance and relationships that a physician uses to provide services for patients, the public, or the profession.” Content of CME ranges from topics on managing healthcare facilities to everyday practice management for

Points of View

DOCTOR SHORTAGE BY 2034

What makes CME effective? What have been the more beneficial CMEs you have been to?

I feel that good presenters going over up-to-date information in a lecture format is most effective to me. I enjoy and feel like I learn more from lecture-style presentations more so than workshops. The most beneficial CME I have been to is the Primary Care Conference here. Actually, Dr. Wilson, one of the family medicine physicians, Dr. Ely (another internal medicine physician), and I coordinate the conference each year. It consists of various UT presenters and we get feedback from the previous years on how to make it better each year. It occurs once a year in early spring.

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Rajiv Dhand, MD, Chair

Among the many problems created or exacerbated by the COVID-19 pandemic; the looming shortage of physicians in the United States is a matter of serious concern. The numbers are truly staggering; in the past three years, 18% of health care workers have quit their jobs! According to a 2020 report by the Association of American Medical Colleges (AAMC), there will be a shortfall of between 37,800 and 124,000 physicians ten years from now. The gap will be felt across a broad range of specialties, but neurology, psychiatry and pulmonary and critical care medicine are projected to have the most significant shortages. However, the greatest need will be felt in primary care. The demand for primary care physicians

and specialists trained to care for the aging population is growing because people over the age of 65 see their physicians much more frequently than younger people. The number of people aged 65 or above in the U.S. is projected to increase by a whopping 42.4% over the next decade! Unless we have more trained physicians, the ability of this elderly population to access the health care system will be compromised. At the same time, the aging of the physician population will further compound this problem. More than 40% of active physicians in the United States will be 65 or older within the next decade, according to the AAMC report. Add to this mix the high-rates of job-related stress and burnout intensified by the COVID-19 pandemic and the need for increasing the number of physicians in the United States to maintain a functioning, physicianled health care workforce becomes even more obvious. The solution for this looming problem lies in training more highly qualified doctors. Physicians spend many more hours in their training compared to other health care providers and there

Patient-Centered Medical Home

As the march of life carries forward, many adults in today’s society struggle to find a balance between their obligations and personal healthcare needs. As a part of a larger effort across Tennessee amongst multiple disciplines, the Department of Medicine is dedicated to the task of becoming a Patient-Centered Medical Home (PCMH). Originally developed for patients with TennCare insurance, a PCMH designation is provided to medical facilities that meet several criteria focused on improving quality of care to the underserved by overcoming barriers more prevalent in these communities.

Work schedules of the patients themselves represent one such barrier, thus, the UT Internal Medicine Center has now made appointments available outside of normal business hours to provide additional options to those with busy schedules. Even with expanded appointment times, patients from these communities often experience challenges of transportation and financial struggles in receiving their care. In light of this, the clinic has recruited additional case management staff to assist more patients in the outpatient setting with these matters. Meeting yet another criterion for PCMH designation, a newly implemented multidisciplinary group huddle has been established within the clinic to anticipate and discuss any special considerations before a busy clinic schedule gets underway.

Lastly, among the many other requirements unable to be discussed at length, the dedication to self-conducted quality improvement must be emphasized to achieve PCMH status in the state of Tennessee. At present, there are multiple quality improvement projects underway within the UT Internal Medicine Center and this requirement has only furthered resident and faculty interest in this cause. In closing, the Department of Medicine would like to thank Dr. Juli Williams, Kay Rangnekar, and Shelby Moses for their efforts in pursuit of the prestigious PCMH designation.

Going Above & Beyond for Our Community

Dr. Janet Purkey serves as the Clerkship Director of the medical students during their medical rotation for the Graduate School of Medicine, and she demonstrates to all the medical students and residents what it means to practice medicine with a servant’s heart She has dedicated both time and resources into establishing the East Knox Free Medical Clinic which is open to anyone in need on Monday afternoons regardless of the patient’s financial situation. In addition to serving her patients at the free clinic, her heart of service has impacted many of our own patients in the resident clinic.

Recently, a young female became established in our clinic following a motor vehicle accident where she experienced significant trauma. She had previously been hospitalized and had undergone surgical repair for her injuries; however, at her initial visit in our clinic, she continued having significant pain that ultimately led to depression and a state of overall malnourishment. She had been referred to a pain clinic and physical therapy for assistance with her recovery, and we were focusing on improving her nutrition at each office visit. At subsequent visits, she was slowly showing signs of improvement. However, she had lost her wheelchair once home health services had expired, and we were unable to re-establish her with any home health service nearby. She also expressed difficulty with paying for her Ensure or Boost nutritional supplementation. Dr. Purkey was present in the clinic that day, and immediately stepped in to provide her with the medical supplies necessary to continue her successful recovery. The patient was provided with directions to the East Knox Free Clinic, and Dr. Purkey met her there on the very same day to provide her a free wheelchair, walker, and three boxes of Boost plus. For the first time, I witnessed this patient smile. She was just one of the many patients that Dr. Purkey has gone above and beyond to provide the most compassionate care.

How CME Translates to Better Patient Care

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Do you feel the CME you have been involved with has led to better outcomes for your patients?

It has made me more thoughtful in assessing patients during my practice. It provides me with more accurate and up-to-date information so yes I feel it is has been beneficial overall.

As mentioned before, UTMC offers CME opportunities involving multiple different topics each year that is sponsored by the ACCME. The next CME, which is titled the “5th Annual Targeted Pain Treatment Conference: Awareness, Access, Application” is scheduled for March 31st, 2023. It will cover the ongoing opioid crisis and how Targeted Pain Treatment® may be “an alternate, effective, and comprehensive approach to addressing the cause of pain and improving function and quality of life for patients.” The conference is officially endorsed by the Tennessee Pain Society and will consist of presentations from many different experts in the field of pain management. For more information, visit this link (https://gsm.utmck. edu/cme/targetedpain/).

Resident Spotlight: Dr. Natalie Street

Tennessee is known as the Volunteer State. This nickname was derived over 225 years ago because of Tennessean’s eagerness to step forward in times of war. Each of us has volunteered in some capacity throughout our journey in medicine. It is one way to show compassion towards humankind and give back to the community. It is a gesture that requires only time and effort while expecting nothing in return. This altruistic act can have lasting effects on people.

Natalie Street has embraced being a Volunteer through an organization called “Random Acts of Flowers.” This organization has brought significant joy to patients at UT Medical Center. This organization aims to improve emotional health and well-being of individuals in healthcare facilities by delivering recycled flowers. These flowers come from various places such as weddings, grocery stores, funerals, and florists to name a few. Natalie is passionate about hand delivering flowers to patients at UT Medical Center. It brightens her day to see the happiness in the recipient’s face when they receive their flowers. One individual greatly appreciated the random act of flowers delivered and told Natalie that she was the only person who had visited while in the hospital. Natalie hopes her small gesture will encourage other members in the community to volunteer.

Diversity, Equity, Inclusion Spotlight: Women in Medicine

Eleven out of thirty-eight, or about 29%, of the current residents at the University of Tennessee Knoxville’s Internal Medicine Residency Program are female. Almost 50% of the 2022 – 2023 intern class are female, which was not always the case, according to Dr. Kimberly Morris, MD. Viewing the cataloged internal medicine class pictures tells a story, one of women’s increasing role in medicine at UT’s Graduate School of Medicine in Knoxville, TN. When the internal medicine program began it was initially all-male, but more women became part of the department over time. The first female resident in the internal medicine residency program started her career in 1979 as a transitional year resident, a few years after the program first started. Just three years later in 1981, Dr. Ann Rush became the clinic director which paved the path for more female leadership. Dr. Mary Hedrick, in the class of 1982, eventually became part of the Knox County Health Department. Shortly thereafter, the first female program director was Dr. Lisa Kirkland. Dr. Kimberly Morris was part of the class of 1989 and remembers other female residents, such as Dr. Janet Purkey who graduated in 1990. She recalls there not being as many females in the internal medicine department, but she has noticed a growth over the years. Dr. Tina Dudney for instance, was the first female Chief Resident as a PGY4 from July 1991 to June 1992. After looking through class pictures over the past 44 years, there are many female faces that have made a growing impact on the Department of Medicine.

Faculty & Staff Announcements: New Faculty

We are pleased to welcome Dr. Erin Jackson to the Department of Medicine as Clinical Assistant Professor. Dr. Jackson currently works at University Palliative Care. She completed medical school at East Tennessee State University, James H. Quillen College of Medicine in Johnson City, TN. Dr. Jackson completed a residency in Internal Medicine at University of Virginia Hospital in Charlottesville, VA. This was followed by a fellowship in Hospice and Palliative Care at Northwestern Memorial Hospital in Chicago, IL. Dr. Jackson has received several accolades including the Northwestern Palliative Medicine Teaching Award and Leonard Tow Humanism in Medicine Award. Dr. Jackson is a member of the American Medical Association, American College of Physicians, and American Academy of Hospice and Palliative Medicine.

We are excited to welcome Dr. Mohamed Tageldin to the Department of Medicine as Clinical Assistant Professor. Dr. Tageldin currently works at UT Rheumatology Associates. He completed medical school at Ain Shams University – Faculty of Medicine in Cairo, Egypt. Dr. Tageldin completed a residency in Internal Medicine at Albany Medical Center, Albany, NY. This was followed by a fellowship in Rheumatology at Allegheny General Hospital in Pittsburgh, PA. Dr. Tageldin has several publications and is a member of American College of Rheumatology.

New Staff Member:

We are delighted to welcome Dr. Enambir S. Josan to the Department of Medicine as Assistant Professor. Dr. Josan currently works at University Pulmonary and Critical Care. He completed medical school at Government Medical College, Amritsar, Punjab, India. Dr. Josan completed a residency in Internal Medicine at East Tennessee State University James H. Quillen College of Medicine, Johnson City, TN. This was followed by a fellowship in Pulmonary and Critical Care at Case Western Reserve University MetroHealth Medical Center, Cleveland, OH and Interventional Pulmonology at Ohio State University Wexner Medical Center, Columbus, OH. Dr. Josan has several publications and accolades including Medical Officer to the Prime Minister of India. Dr. Josan is a member of American College of Chest Physicians as well as American Association of Bronchology and Interventional Pulmonology.

We welcome Kaylee Weitz as Internal Medicine Associate Program Coordinator. Kaylee was previously a CNA for UT Family Physicians. After solely working in patient-care, she transferred to the UT Graduate School of Medicine. She works closely with the Internal Medicine Residents to prepare them for graduation. Her goal is to help residents feel supported and develop confidence throughout their academic journey, so they can complete their residency as outstanding future doctors.

Employee Spotlight:

Cheryl Teague is the Graduate School of Medicine’s Fellowship Program Coordinator for the Cardiovascular Disease, Pulmonary Critical Care Disease, and Interventional Cardiology Fellowships. Prior to Joining UT Graduate School of Medicine in 2021, she was employed as an administrative assistant to the System Administrator of Ambulatory Services at Appalachian Regional Healthcare in KY. In addition, she was an office manager for a private practice cardiology office. Cheryl thoroughly enjoys her position with the Department of Medicine and states, “I am forever grateful for the opportunity to work in a prestigious healthcare organization like UTGSM. I have learned so much in my two short years and look forward to many more years of learning and growth”.

Points of View

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should not be any compromise on the quality and duration of this training. The number of medical students who graduate each year and available residency positions must be increased. Recently, the United States Congress overrode the almost 25-year freeze on Medicare support for Graduate Medical Education (GME) by adding 200 new residency positions for 5 years, mainly in underserved rural and urban communities. The State of Tennessee also provided 15 additional residency positions in primary care this past year. While these measures are important steps, they will need to be greatly enhanced to meet the requirement for additional physicians. Unfortunately, there is a tendency to adopt short-term fixes to what is essentially a long-term problem. These patchwork measures have the potential to undermine the current health care system because if supply does not meet demand, each physician will be required to do even more, further increasing the rates of burnout among them. As physicians, we all have a responsibility to train many more doctors to meet the demands for excellent patient care while preserving our own mental and physical health.

CME OPPORTUNITIES—MARK YOUR CALENDARS!

• Cardiology Conferences, held weekly on Wednesdays from 12:15 – 1:00pm in the Medicine Conference Room and are available for 0.75 hour CME credit.

• Medicine Grand Rounds, held on the 2nd & 4th Tuesdays each month from 8:00-9:00am in the Medicine Conference Room and are available for 1.00 hour CME credit.

• Ethics Case Rounds, held on the 4th Thursday of each month from 12:00-1:00pm in Wood Auditorium and are available for 1.00 hour CME credit.

• Pulmonary/HTN Conferences, held on the 2nd Monday each month from 12:00 – 1:00pm, in different locations and are available for 1.00 hour CME credit.

Scholarly Activity

CARDIOVASCULAR DISEASE PUBLICATIONS:

Fogelson B, Livesay J, Rohrer M, Edwards M, Hirsh JB. Prevotella bivia cardiac implantable electronic device related endocarditis. IDCases. 2022;28:e01499.

Published 2022 Apr 9. doi:10.1016/j.idcr.2022.e01499. PMID: 35464738

Goodwin E, Fogelson B, Cox JW Jr, Mahlow WJ. An algorithm for pacing and cardioverting electronic devices undergoing magnetic resonance imaging: The PACEDMRI protocol. Magn Reson Imaging. 2023;96:44-49. doi:10.1016/j.mri.2022.10.012. PMID: 36441043

Stephens S, Fogelson B, Goodwin RP, Baljepally GK, Baljepally R. Takotsubo Cardiomyopathy secondary to cryptococcal meningoencephalitis in a patient With multiple sclerosis. J Med Cases. 2022;13(6):263-268. doi:10.14740/jmc3884. PMID: 35837075

Isang E, Stephens S, Coombes T, Abney L, Baljepally G. Left atrial thrombus after placement of watchman device. Clin Case Rep. 2022;10(10):e6410. Published 2022 Oct 22. doi:10.1002/ccr3.6410. PMID: 36285035

Almeida S, Shaikh K, Memon S, Singh V, Thomas D. Harnessing imaging biomarkers to refine individualized cardiovascular disease risk: a case-based discussion. Coron Artery Dis. 2022 Nov 1;33(7):574-579. doi: 10.1097/MCA.0000000000001173. Epub 2022 Aug 9. PMID: 35942620.

Lee J, Shaikh K, Nakanishi R, Gransar H,Achenbach S, Al-Mallah MH, Andreini D, Bax JJ, Berman DS, Cademartiri F, Callister TQ, Chang HJ, Chinnaiyan K, Chow BJW, Cury RC, DeLago A, Feuchtner G, Hadamitzky M, Hausleiter J, Kaufmann PA, Kim YJ, Leipsic JA, Maffei E, Marques H, de Araújo Gonçalves P, Pontone G, Rubinshtein R, Villines TC, Lu Y, Peña JM, Lin FY, Min JK, Shaw LJ, Budoff MJ. Prognostic significance of nonobstructive left main coronary artery disease in patients with and without diabetes: long-term tutcomes from the CONFIRM registry. Heart Lung Circ. 2022 Nov 3:S1443-9506(22)01126-X. doi: 10.1016/j. hlc.2022.09.014. Epub ahead of print. PMID: 36336615.

Shaikh K, Ahmed A, Gransar H, Lee J, Leipsic J, Nakanishi R, Alla V, Bax JJ, Chow BJW, Berman DS, Maffei E, Lin FY, Ahmad A, DeLago A, Pontone G, Feuchtner G, Marques H, Min JK, Hausleiter J, Hadamitzky M, Kaufmann PA, de Araújo Gonçalves P, Cury RC, Kim YJ, Chang HJ, Rubinshtein R, Villines TC, Lu Y, Shaw LJ, Acenbach S, Al Mallah MH, Andreini D, Cademartiri F, Callister TQ, Budoff MJ. Extent of subclinical atherosclerosis on coronary computed tomography and impact of statins in patients with diabetes without known coronary artery disease: Results from CONFIRM registry. J Diabetes Complications. 2022 Dec;36(12):108309. doi: 10.1016/j. jdiacomp.2022.108309. Epub 2022 Sep 15. PMID: 36444796

Goodwin E, Fogelson B, Cox JW Jr, Mahlow WJ. An algorithm for pacing and cardioverting electronic devices undergoing magnetic resonance imaging: The PACEDMRI protocol. Magn Reson Imaging. 2023 Feb;96:4449. doi: 10.1016/j.mri.2022.10.012. Epub 2022 Oct 27. PMID: 36441043

Taylor J, Assaf A, Assaf M, Assaf S, Shepple B, Kassira A. Pulmonary Fibroelastoma: A Rare Cardiac Mass Presenting With Dyspnea. CASE. 2022, ISSN 2468-6441, https://doi.org/10.1016/j.case.2022.10.003

Almeida S, Shaikh K, Memon S, Singh V, Thomas D. Harnessing imaging biomarkers to refine individualized cardiovascular disease risk: a case-based discussion. Coron Artery Dis. 2022 Nov 1;33(7):574-579. doi: 10.1097/MCA.0000000000001173. Epub 2022 Aug 9. PMID: 35942620.

Fogelson B, Black W, Goodwin RP, Dieter R 3rd, Baljepally R. Asymptomatic Aorto-Atrial Fistula Secondary to Surgical Repair of Ascending Aortic Dissection: When to Do Nothing. JACC Case Rep. 2022 Jul 20;4(14):868-870. doi: 10.1016/j. jaccas.2022.04.013. eCollection 2022 Jul 20

Livesay J, Fogelson B, Tahir H, Baljepally R. Comparison of Tricuspid Regurgitation Severity Between Cardiac Resynchronization Therapy Versus Right Ventricular Pacing in Patients With Chronic Obstructive Pulmonary Disease. Cardiol Res. 2022 Jun;13(3):128134. doi: 10.14740/cr1365. Epub 2022 Jun 16.

Baljepally R, Tahir H, Goodwin RP, Livesay J, Fogelson B, Patel C, Coombes T, Wadi G, Dieter R 3rd. Comparison of Transcatheter Aortic Valve Implantation Outcomes Between Normal-Flow, Low-Gradient Severe

Aortic Stenosis and Normal-Flow, High-Gradient Severe Aortic Stenosis. Cardiovasc Revasc Med. 2022 Jun;39:12-17.doi: 10.1016/j.carrev.2021.10.020. Epub 2021 Nov 2

Fogelson B, Goodwin RP, Tahir H, Baljepally R. Rural Versus Urban Outcomes Following Transcatheter Aortic Valve Implantation. JSCAI. 2022 May 01. p. 100183

Tahir H, Livesay J, Fogelson B, Coombes T, Patel C, Baljepally R. Use of the CHA2DS2-VASc Score in Assessing Transradial Approach Failure. Cardiovasc Revasc Med. 2022 Mar;36:107-112. doi: 10.1016/j. carrev.2021.05.023. Epub 2021 May 28. PMID: 34140231.

Livesay J, Baljepally R, Fogelson B, et al. Short-Term Outcomes after Transcatheter Aortic Valve Implantation in Low Flow Low Gradient Versus Normal Flow Low Gradient Aortic Stenosis. J Am Coll Cardiol. 2022 Mar, 79 (9_Supplement) 679.

Tahir H, Livesay J, Baljepally R, et al. Improving Impella Hemodynamics Using Temporary Atrioventricular (AV) Sequential Pacing in a Patient with Cardiogenic Shock and Complete Heart Block. J Am Coll Cardiol. 2022 Mar, 79 (9_Supplement) 3430

Goodwin E, Goodwin RP, Abney L, et al. Bevacizumab-Associated Left Anterior Descending Artery Occlusion in a Young Woman with Neurofibromatosis type 2. J Am Coll Cardiol, 2022 Mar, 79 (9_Supplement) 2210. Doi: 10.1016/S0735-1097(22)03201-6

Fogelson B, Tahir H, Livesay J, Baljepally R. Pathophysiological factors contributing to fractional flow reserve and instantaneous wave-free ratio discordance. Rev Cardiovasc Med. 2022 Feb 18;23(2):70. doi: 10.31083/j.rcm2302070

Fogelson B, Livesay J, Johnson JH. Inferior Myocardial Infarction Secondary to Coronary Artery Vasospasm Following Regadenoson Stress Imaging. J Med Cases. 2022 Jan;13(1):11-14. doi: 10.14740/ jmc3850. Epub 2022 Jan 17. PMID: 35211229; PMCID: PMC8827252

PULMONARY CRITICAL CARE PUBLICATIONS

Bhagat M, Singh A, Bazzi T, Green J. Bronchorrhea: a rare and debilitating symptom of lung cancer: case report and review of the treatment. JTO Clinical and Research Reports. 2022 Oct;3(10) https://doi.org/10.1016/j. jtocrr.2022.100398. PMID: 36164316

Vijayan K, Karakattu SM, Bansal A, Thomas A, Alazzeh A, El Minaoui W, Maisonet M. Immediate complications and flow volume changes during treatment phases of bronchial thermoplasty: a single-center descriptive study. J Asthma. 2022 Jul;59(7):1433-1437. doi: 10.1080/02770903.2021.1924775. Epub 2021 May 18. PMID: 33947298.

Zhou CY, Sahay S, Shlobin O, Soto FJ, Mathai SC, Melendres-Groves L, Mullin CJ, Levine DJ, Kay D, Highland K, Bossone E, Poms A, Memon H, Balasubramanian V, Farmer MJS, Rahaghi F, Elwing JM. Effects of COVID-19 pandemic on the management of pulmonary hypertension. Respir Med. 2023 Jan;206:107061. doi: 10.1016/j.rmed.2022.107061. Epub 2022 Nov 26. PMID: 36493604; PMCID: PMC9699715 Wong F, Doyle-McClam M, Pugh S, Dudney T, McCormack M, Kravitz J. Diagnostic and treatment dilemma during the coronavirus disease 2019 pandemic: a primary pulmonary lymphoma presenting as a cavitary mass in a patient with coronavirus disease 2019: a case report. J Med Case Rep. 2023 Jan 13;17(1):12. doi: 10.1186/s13256-022-03745-5. PMID: 36635758; PMCID: PMC9836925

Fogelson B, Qu D, Bhagat M, Branca PR. Multiorgan system failure secondary to difluoroethane toxicity in a patient “huffing” air duster: a case report. J Addict Dis. 2022 Oct-Dec;40(4):577-582. doi: 10.1080/10550887.2022.2027207. Epub 2022 Jan 19. PMID:35044291.

Olanipekun T, Abe T, Effoe V, Chris-Olaiya A, Biney I, Guru P, Ritchie C, Sanghavi D. Utilization trends and outcomes of catheter-directed thrombolysis for pulmonary embolism in the US by race/ethnicity. J Thromb Thrombolysis. 2022 Nov;54(4):675-685. doi: 10.1007/ s11239-022-02710-9. Epub 2022 Oct 11. PMID:36219337.1

Zhou CY, Sahay S, Shlobin O, Soto F, Mathai S, Melendres-Groves L, Mullin CJ, Levine DJ, Kay D, Highland K, Bossone E, Poms A, Memon H, Balasubramanian V, Farmer MJS, Rahaghi F, Elwing JM. Effects of COVID-19 pandemic on the management

of pulmonary hypertension. Respir Med. 2023 Jan;206:107061. doi: 10.1016/j.rmed.2022.107061. Epub 2022 Nov 26. PMID: 36493604.

Soto FJ, Biney IN, Akhtar Y, McKeown PP, Turner JF. Abnormal Cardiac Ultrasound Imaging in a Patient With Sudden Neurologic Deficit. Chest. 2022 Sep;162(3):e145-e148. doi: 10.1016/j. chest.2021.09.043

Li J, Alolaiwat A, Fink JB, Dhand R. AerosolGenerating Procedures and Virus Transmission. Respir Care. 2022 Aug;67(8):1022-1042. doi: 10.4187/ respcare.10160. Epub 2022 Apr 6

Harnois LJ, Alolaiwat AA, Jing G, Fink JB, Dhand R, Li J. Efficacy of Various Mitigation Devices in Reducing Fugitive Emissions from Nebulizers. Respir Care. 2022 Apr;67(4):394-403. doi: 10.4187/respcare.09546. Epub 2021 Nov 9

Li J, A Alolaiwat A, J Harnois L, Fink JB, Dhand R. Mitigating Fugitive Aerosols During Aerosol Delivery via High-Flow Nasal Cannula Devices. Respir Care. 2022 Apr;67(4):404-414. doi: 10.4187/respcare.09589. Epub 2021 Nov 17. PMID: 34789564

Sahay S, Balasubramanian V, Memon H, Poms A, Bossone E, Highland K, Kay D, Levine DJ, Mullin CJ, Melendres-Groves L, Mathai SC, Soto FJ, Shlobin O, Elwing JM. Utilization of risk assessment tools in management of PAH: A PAH provider survey. Pulm Circ. 2022 Apr 8;12(2):e12057. doi: 10.1002/pul2.12057. eCollection 2022 Apr

Swanson CS, Dhand R, Cao L, Ferris J, Elder CS, He Q. Microbiome-based source identification of microbial contamination in nebulizers used by inpatients. J Hosp Infect. 2022 Apr;122:157-161. doi: 10.1016/j. jhin.2022.01.008. Epub 2022 Jan 23

Zarogoulidis P, Kosmidis CS, Hohenforst-Schmidt W, Matthaios D, Sapalidis K, Petridis D, Perdikouri EI, Courcoutsakis N, Hatzibougias D, Arnaoutoglou C, Freitag L, Ioannidis A, Huang H, Tolis C, Bai C, Turner JF. Radial-EBUS: CryoBiopsy Versus Conventional Biopsy: Time-Sample and C-Arm. Int J Environ Res Public Health. 2022 Mar 17;19(6):3569. doi: 10.3390/ ijerph19063569

Ohar JA, Ferguson GT, Mahler DA, Drummond MB, Dhand R, Pleasants RA, Anzueto A, Halpin DMG, Price DB, Drescher GS, Hoy HM, Haughney J, Hess MW, Usmani OS. Measuring Peak Inspiratory Flow in Patients with Chronic Obstructive Pulmonary Disease. Int J Chron Obstruct Pulmon Dis. 2022 Jan 6;17:79-92. doi: 10.2147/COPD.S319511. PMID: 35023914; PMCID: PMC8747625

Dhand R. Inhaled Tobramycin for Treatment of Ventilator-Associated Pneumonia: The Interplay of Patient, Drug, and Device. Respiratory Care January 2022, 67 (1) 151-153; https://doi.org/10.4187/ respcare.09852

Gutierrez A, Gerbo M, Treat S, Sharma N, Jordan S, Dudney T. A New Meaning to Chest Tightness: Tension Pneumomediastinum and Bedside Mediastinotomy In SARS- CoV-2. Critical Care Medicine: January 2022 – Volume 50 - Issue 1 - p 131. doi: 10.1097/01. ccm.0000807484.94614.ad

OTHER PUBLICATIONS:

Svynarenko R, Lindley LC, Mooney-Doyle K, Mendola A, Naumann WC, Mack JW. Patterns of healthcare services among children with advanced cancer in concurrent hospice care. Cancer Nurs. 2022 Nov-Dec 01;45(6):E843-E848. doi: 10.1097/ NCC.0000000000001067. Epub 2022 Feb 16. PMID:35175949.

Schildkraut JM, Johnson C, Dempsey LF, Qin B, Terry P, Akonde M, Peters ES, Mandle H, Cote ML, Peres L, Moorman P, Schwartz AG, Epstein M, Marks J, Bondy M, Lawson AB, Alberg AJ, Bandera EV. Survival of epithelial ovarian cancer in Black women: a society to cell approach in the African American cancer epidemiology study (AACES). Cancer Causes Control. 2022 Dec 15:1-15. doi: 10.1007/s10552-022-01660-0. Online ahead of print. PMID:36520244.

Zayas LE, Walker RH. Amantadine treatment for hyperkinetic movements in chorea-acanthocytosis. Mov Disord Clin Pract. 2022 Dec 20;10(2):346-347. doi: 10.1002/mdc3.13623. eCollection 2023 Feb. PMID: 36825061.

Ethics Case Rounds

Ethics Case Rounds are monthly, hospital-wide discussions of morally distressing cases. Cases are deidentified to protect patient confidentiality.

“Roberta” is a 40-year-old lady, 18 weeks pregnant, who was admitted for increased dyspnea due to COVID-19. She reported good fetal movement and denied vaginal bleeding, loss of fluid, and contractions. She lived with her husband and their five children about 90 minutes away. They have supportive family nearby. She and her family tend to avoid conventional medicine and prefer to maintain health with diet, exercise, meditation, and herbal remedies. She delivered her children at home and plans to do the same for this baby. She declined Remdesivir and only reluctantly agreed to supplemental oxygen by nasal cannula.

Unfortunately, Roberta’s condition worsened. Her physician strongly encouraged her to reconsider Remdesivir. She declined, saying she prefers to avoid medications, especially since she is pregnant. She was also worried that use of oxygen by nasal cannula would create a dependence on oxygen therapy. Her physician explained the effects of the medications and oxygen therapy, their risks and benefits, and expected sequelae with/without them. Roberta continued to decline Remdesivir but agreed to reconsider if she continued to worsen.

Roberta’s oxygen needs continued to increase. By day 5, she had accepted Remdesivir and high-flow nasal cannula at 10L/min but was very frustrated with the hospital milieu and wanted to leave against medical advice (AMA). She felt she would do better at home, where she has access to healthy food, her own bed, sunshine and fresh air, and freedom to move around. “I don’t care about numbers -- I know my body and my baby.” Her physicians believed her oxygen needs were too great for her to be at home safely. Moreover, if she suffered a rapid deterioration, it could have catastrophic consequences for her and her baby. An ethics consult was requested.

Informed Choice and Pregnancy

It is very common for pregnant patients to decline an intervention(s) at some point during pregnancy, birth, or postpartum. Most providers accept when informed, capacitated patients refuse an intervention. Unfortunately, a significant minority of providers respond with disrespect, attempts to coerce, and even to proceed over the patient’s objections. Patients whose providers responded with disrespect, coercion, or force reported responses ranging from disappointment to trauma. They were also more likely to avoid medical care in future. In contrast, patients who trust their health care providers are more likely to accept recommendations and are more willing to collaborate when they do decline an intervention.

The ethical principle of patient autonomy and the goal of informed choice is not diminished by pregnancy. Health care providers have the responsibilities to ensure that patients, including pregnant patients are informed of risks, benefits, and alternatives, have decision making capacity for the decisions at hand, and are not making decisions under duress.

Roberta’s care team met with her and her family to discuss how to maximize the well-being of Roberta and her fetus. All agreed with a plan to maintain as homelike an atmosphere as possible (e.g., no routine vitals from 8pm6am, family would bring food from home) and try to wean her oxygen needs to a level that could be provided at home. If she could maintain adequate oxygen saturation, then her recovery could be managed at home. If not, the plan was to continue the hospitalization.

The day she completed her course of Remdesivir, she was maintaining oxygen saturations in the mid-90s on <6L of oxygen per minute and again asked to leave AMA. Her providers felt she should stay but worked with her to develop a plan for her to continue with her medications and oxygen at home, to monitor her oxygen needs, and to return to the hospital if needed.

Comments on this case may be sent to amendola@utmck.edu

References

• Informed Consent and Shared Decision Making in Obstetrics and Gynecology: ACOG Committee Opinion Summary, Number 819. Obstet Gynecol. 2021;137(2):392-393. doi:10.1097/AOG.0000000000004248

• Kotaska A. Informed consent and refusal in obstetrics: A practical ethical guide. Birth. 2017;44(3):195-199. doi:10.1111/birt.12281

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In Touch

Vol. 121 Issue 5:

January 2023

Publisher

Rajiv Dhand, MD, Chair, Department of Medicine and Associate Dean of Clinical Affairs

Editor

Annette Mendola, PhD

Administrative Director

Jenny Roark

Contributors

Jenny Roark

Robin Underwood

Rajiv Dhand, MD

Annette Mendola, PhD

Cassandra Mosley

James Drew, MD

Marc Oropilla, DO

Shawna Stephens, DO

Ashley Gutierrez-Santana, MD Add Erin Hamric, DO Logan Shaver, DO

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J Squared Graphics

In Touch is produced by the University of Tennessee Graduate School of Medicine, Department of Medicine. The mission of the newsletter is to build pride in the Department of Medicine by communicating the accessible, collaborative and human aspects of the department while highlighting pertinent achievements and activities.

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Disclaimer: quotes/ interviews are edited for length and clarity