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Inhalation of elemental mercury is a rare cause of ARDS, with limited published case reports to provide guidance regarding disease progression and management. Although extracorporeal membrane oxygenation (ECMO) has been used to treat toxin-induced lung injury, its application to initial treatment and long-term recovery for inhalation of mercury remains undescribed. We present a case of a 56-year-old man who works at a thermometer factory presenting with severe ARDS secondary to inhaled elemental mercury with confirmatory blood and urine mercury levels. Respiratory recovery and avoidance of neurologic and renal sequelae from elemental mercury was successfully accomplished with venovenous ECMO, steroids, and simultaneous dual-chelation therapy. This case demonstrates the efficacy of venovenous ECMO for severe inhalation of elemental mercury pulmonary injury and the utility of dual-chelation therapy for avoiding late development of neural and renal pathologic conditions and provides novel insight into the impact of ECMO circuits on blood mercury levels.

The advanced practice respiratory therapist (APRT) is a new health care practitioner trained to provide a scope of practice that exceeds that of the registered respiratory therapist (RRT) and is aligned with an advanced practice provider (APP) role. As part of a physician-led team, APRTs are trained to provide diagnostic and therapeutic patient care services in multiple settings across the health care spectrum, including critical care, acute and subacute inpatient care, and outpatient care such as preventative, ambulatory, and chronic care. Competency domains that must be included in accredited APRT education programs include medical knowledge, interpersonal and communication skills, patient care, professionalism, practice-based learning and improvement, and systems-based practice. Some of the individual competencies included in these domains must be incorporated into didactic coursework, some into laboratory and simulation activities, and all competencies must be incorporated into clinical coursework. Preclinical preparation of the APRT student includes coursework with other APP students and other health professions students, and courses created specifically to address the required competency domains. APRT students also complete a variety of patient simulations using standardized patients, task trainers, and patient simulators to ensure they are prepared to complete clinical education. The clinical courses include a minimum of 1,200 hours of supervised practice by a licensed physician in outpatient clinics, interventional pulmonology, inpatient pulmonary services, perioperative services, and ICUs. The APRT is trained to assess patients, develop care plans, and order, evaluate, and modify care based on each patient's response, and can be incorporated as a valuable member of the cardiopulmonary patient care team.

A 72-year-old man with metastatic pancreatic cancer was admitted to the ICU with increased oxygen demand and confusion, likely related to pulmonary metastases. In the presence of his son, the health care agent, and the team, the patient requested to be do not attempt resuscitation and do not intubate status before losing decision-making capacity. When the patient's brother and another son heard of the code status change, they insisted on a return to Full Code. Although the youngest son (the health care agent) was present for the patient's request to be do not attempt resuscitation/do not intubate, he declined to represent the patient's wishes and agreed with a return to Full Code. Numerous discussions over subsequent days revolved around the attempt to honor the patient's wishes in the setting of the surrogate's unwillingness or inability to make decisions in alignment with his father's wishes. This case reviews and analyzes the ethical options available to the clinical team in responding to requests for potentially inappropriate treatment at a patient's end of life and explores the roles of relational autonomy, beneficence vs nonmaleficence, and holding the balance of clinicians' and ethicists' professional, legal, and ethical responsibilities.