Vignette Background: Sharon is a 56-year-old woman who has been complaining of bloating and discomfort for years. While descending steps from her hillside home, she recently fell and fractured her pelvis. A CT of the pelvis revealed a large ovarian mass with smaller masses in the peritoneum, and studies of the chest and upper abdomen revealed masses in the liver and lung. A recent biopsy confirmed poorly differentiated cells. She was diagnosed with metastatic ovarian carcinoma and managed conservatively for the pelvic fracture. Until last month Sharon ran a preschool, but she has been homebound for weeks. Presentation: Now, a month after the fracture, Sharon has developed increasing shortness of breath and has been admitted to the hospital with fever and pulmonary infiltrates bilaterally. She appears weak and delirious and has a raspy cough and signs on examination of extensive lung consolidation. She has lost a substantial amount of weight since last month. She is receiving high-flow oxygen 100% in the ICU, as well as antibiotics and vasopressors. At Sharon’s bedside is her 24-year-old daughter, who lives with her and works at the preschool. Her 30-year-old son, who has been working in South America, has not seen his mother in years. He arrives from the airport tonight. Sharon’s spouse Frank cannot be with her as he had been hospitalized only days earlier due to complications of Parkinson’s. Sharon has no written advance directive documented. The primary physician on the case, her oncologist, has requested the assistance of a pulmonologist and an orthopedist. The charge nurse asks the attending-of-record to consider involving the palliative care service, but the physician responds that “this is not the time.” A night shift nurse places a call to Clinical Ethics.

Vignette: A 57-year-old man was brought into the emergency department by paramedics for altered mental status. He was noted to be in his usual state of health the morning of the event when he became confused, vomited, and was observed to fall on the floor without trauma to the head. His baseline health was notable for diabetes mellitus, schizoaffective disorder, history of one prior hospitalization in 2009 for lithium toxicity, hyperlipidemia, and genital herpes. The patient’s wife, at bedside, denied that he used tobacco, alcohol, or street drugs. Living with him in the community, his wife indicated that the patient had a progressive brain disease and possibly early dementia, but she denied any impairment of activities of daily living. The spouse brought to the hospital a signed living will requesting no extraordinary measures in case of a coma with little hope of recovery. His “living will” also specified that he would refuse mechanical ventilation or tube feeding even for reversible conditions. The patient was found to have severe acidosis, multiorgan dysfunction, transaminases elevated to the 6000 U/L level, and an acetaminophen level of 465 mg/L. Shortly after routine therapy was initiated, a signed note was brought in from the patient’s home stating the following: “I am doing this before my brain disease overtakes me.” Clinical ethics is urgently consulted about whether to proceed with emergent dialysis, mechanical ventilation, and evaluation for liver transplantation. We present 3 perspectives on whether to treat and how to proceed in the setting of a potential suicide attempt with an advance directive limiting care options.

Vignette A 36-year-old homeless man was brought in to the emergency room with altered mental status and was unable to give a history. Based on prior emergency visits, he has a history of IV drug abuse and alcohol abuse. His vital signs on arrival are the following: HR of 110 (regular), BP of 102/58, temperature of 98.0, and respiratory rate of 8/min. His Glasgow Coma Scale score is 7. Physical examination results are that he is grossly obtunded, responds only to deep painful stimuli, is nonverbal, and moves all extremities. Pupils are small, 2 to 3 mm, and reactive. His heart reveals regular tachycardia. Lungs are clear to auscultation. Abdomen is within normal limits. His extremities are warm to touch. Skin reveals ecchymosis. His initial head CT finding is negative for bleeding, infarct, or mass. He has severe metabolic acidosis, and the urine toxin screen result is positive for cocaine and opiates. His creatinine kinase enzyme is greater than 20,000 IU/L. Peripheral venous access attempts are unsuccessful. The right internal jugular vein is accessed via a needle with ultrasound guidance, but a guidewire failed to pass on multiple attempts. The emergency physician inserts a right femoral line triple lumen catheter without ultrasound. The patient is intubated via an endotracheal tube for airway protection and admitted to the medical ICU.

In this 2-part article, we hope to join the reader in the broader discussion over ICU staffing. From the perspective of the clinician, we provide references to central concepts and landmark studies identifying organizational elements linked to patient outcomes. From the perspective of the unit management, we provide access to the literature on clinician interaction and organizational ethics. From the human resources (HR) literature, we provide relevant principles, standard practices, and concerns that should alert clinicians to seek HR and risk management consultation. In Part 1, we introduce many of the concepts relevant to staffing, hiring, and orienting teams toward performance. In Part 2, we explore management and business models as well as unit operations in relation to staff interests and concerns. The primer encourages managers and directors as well as clinicians and support staff to take a mindful stroll through each others’ concerns and published literature.

In this the second part of a 2-part ICU staffing series, we enjoin the reader to enter the multidisciplinary discussion over the broad issue of ICU staffing. Part 1 (vol. 1 no. 2, March 2010) emphasized evidence based, patient-centered staffing and outlined some challenges from a nursing and staffing perspective. The section outlined principles, standard practices and human resources concerns for the clinician, manager and ICU director. In part 2, we explore design, management and business models as well as unit operations in relation to ICU staff and ICU patients. It includes evidence behind key concepts linking ICU structure, team design and staffing. The primer encourages ICU leaders to step out of the weeds and take a walk in the woods to explore each others’ perspectives and literature.

Case The patient is a 20-year-old male who was a pedestrian struck by a moving motor vehicle at a speed of 40 to 50 miles per hour. He was brought in to the emergency department (ED) with a Glasgow Coma Scale score of 5 (V1, E2, M2). He was intubated in the ED. His vital signs were as follows: heart rate of 126 beats per minute, blood pressure of 130/78, spontaneous breathing but on the ventilator, and neurological examination consisting of flexor posturing in the upper extremities and slight withdrawal in the lower extremities. His pupils were 4 mm and reactive, there was no blink to threat, and he did not open his eyes to voice or deep stimuli. His initial CT head scan demonstrated a small left subdural hematoma, blood in the left lateral ventricle, a left orbital fracture, and a right occipital fracture. Subsequent imaging also showed pneumocephalus in the anterior horns of the lateral ventricles and small blood in the posterior pons. This hospital has a designated specialized neuro-ICU, with 24/7 coverage, residents, and NPs. However, there were no beds available at this time. The patient was admitted to a medical-surgical ICU.

Case:Mrs. Smith is an 85-year-old woman with longstanding chronic kidney disease (NKF Stage 5, <15 mL per 1.73 m2) who has been on hemodialysis for the past year. She is admitted to the intensive care unit from the community with acute respiratory distress syndrome. Her comorbidities include diabetes and hypertension (JNC7 Hypertension, Stage 2). The patient receives empiric treatment for health-care-associated pneumonia but remains ventilator dependent and on a high FIO2 after 2 weeks. The patient is off vasopressors.

In this the second part of a 2-part ICU staffing series, we enjoin the reader to enter the multidisciplinary discussion over the broad issue of ICU staffing. Part 1 (vol. 1 no. 2, March 2010) emphasized evidence based, patient-centered staffing and outlined some challenges from a nursing and staffing perspective. The section outlined principles, standard practices and human resources concerns for the clinician, manager and ICU director. In part 2, we explore design, management and business models as well as unit operations in relation to ICU staff and ICU patients. It includes evidence behind key concepts linking ICU structure, team design and staffing. The primer encourages ICU leaders to step out of the weeds and take a walk in the woods to explore each others’ perspectives and literature.