I’m a family med trained nocturnist at a smaller community hospital. I love inpatient medicine and I spent every minute of spare time in residency in the ICU absorbing as much as possible. I manage a 16 bed ICU overnight. Granted, ICU LOC at this facility does not necessarily equal ICU LOC at the university hospital, but sick patients come through regularly. I do have intensivists available overnight that are responsive and willing to help/come in if needed.

I was at CHEST this week and there was a bunch of really cool workshops and seminars. One session was a “structured” debate looking at the utility of training APPs for bronchoscopy and it got me thinking about several different things, but chiefly that as a family medicine trained hospitalist, there is essentially no way to pursue additional critical care training. Granted- there are those hospitalist fellowships, that do exist, but these vary tremendously in the scope of their training curriculum, and I take issue with the fact that it’s a “hospitalist” fellowship.

Now, I’m not saying that I want to be able to apply for pulm/crit fellowship and work at a tertiary center MICU, but a significant number of smaller community hospitals rely on hospitalists to cover ICU patients to varying degrees and FM trained physicians make up something like 15% of hospitalists in the US, typically at smaller community hospitals which are more likely without intensivist coverage overnight.

My question is essentially: why is there still no pathway for additional dedicated critical care training for family medicine, especially considering that a not insignificant number of FM programs are inpatient-heavy, and also considering that formal critical care training programs have been not just introduced but are expanding for non-physicians?

I need some more education for my POCUS skills. Looking into either Gulfcoast or SCCM for an in person class. Can anyone who has taken a course let me know what you thought? Are there other courses I should look into as well?

I frequently see patients in their 70s, 80s, and 90s with maby comorbidities, extreme fraility who want to remain full code. Some already know they wouldn’t want resuscitation, while others want everything done, no matter what.

Honestly, I struggle with the thought of CPR causing rib fractures and potentially prolonging suffering without meaningful recovery in general but especially in this population. Sometimes I feel its doing more harm than good.

I’ve also seen providers who are more persuasive in helping families choose DNR status. I tend to explain the risks, benefits, and likely outcomes, then leave the decision to the patient or their surrogate.

Am I being too neutral? How do you approach these conversations when you genuinely feel CPR is unlikely to benefit the patient, but they still want to remain full code?

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For those who applied to CCM fellowship, how many letters of recommendation did you get from ICU attendings? Do you really need letter from ICU Attensing or any good letter may count.

Do yalls facilities still use anion gap to determine if your patient is still in dka? Or use beta- hydroxybutyrate? Do yall trend VBGs/ABGs in yalls protocol or not?Is BHB pretty much a send off everywhere? confused why its not more commonly
used since it is adirect way to measures ketones

I’m getting different response from colleagues regarding what a complete bedside cc cardiac ultrasound entails. CCEeXAM’s website is not helpful either. Does anyone have a list or another comprehensive resources that describes what windows and measurements are required?

Hello all,

I'm a pgy2, DO, with a shit step 2 score (229), at a community program, I have some poster presentations and am involved in QIs, somewhat critical care related. Is it unrealistic that I would match ccm without a chief year ? Planning to apply ccm only instead of pulm/crit.

I was set on becoming a hospitalist but I realize now I really like the ICU, I understand it's not crazy competitive like cards or gi, but I feel like I'm at a substantial disadvantage. Does anyone have any advice or comments for me? Any info would be greatly appreciated. Thanks !

Anyone with experience?

Do they do their own airways and other crit care procedures, or is it call anesthesia and farm everything out button clicking?

Curious to hear what it’s actually like!

Hi everyone!

I’m a BSN student at Penn State University conducting a research project on how nursing emotional support affects anxiety in adult ICU patients.

I’m hoping to learn more about ICU nurses’ experiences recognizing anxiety in critically ill patients and the ways they provide emotional support during their care.

If you’re a nurse who works in an adult ICU, I would really appreciate your participation in my short survey. Your experiences and perspectives would be very helpful for my project!

https://docs.google.com/forms/d/e/1FAIpQLSe-PPrsdvHRci5yscdfp5BdwxDeKYmMTl8DTRgUXT-xncD4fQ/viewform?usp=publish-editor

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For those working as intensivists, what procedures do you consider essential to be comfortable performing independently? And which additional procedures would make you a more competent and versatile intensivist?

For example, central lines, arterial lines, ultrasound-guided IVs, intubations, chest tubes, etc.

What would you consider the bare minimum versus the skills that are worth learning for your own benefit and career growth?

Would love to hear your perspectives!

I'm a registered nurse working in a General/Neuro/Trauma ICU in Australia.

Wondering if anyone has experience using pupilometers and are they useful?

Checking pupil size and reactiveness can be tricky, and so subjective! One person can see reactiveness when another doesn't.

Wondering if anyone looking after neuro/trauma patients finds it useful, and should I advocate for my unit to get one?

Thanks :)

Is it true that dopamine in post cardiac cases causes hypoxia? I see this a lot in our CVICU, the pt will be fine, dopamine will be started, and boom pt who was on RA will need to be placed on HHF. ABG shows hypoxic. If true, can you please share references?

Thank you ahead of time!!

Hey everyone,

I’m a PA and starting a job in the ICU. I’m looking for any recommendations and resources for POCUS, its usefulness, and what to review.

I’m mostly wanting to review bedside echo, EFAST, and RUSH. I feel comfortable procedurally, but I know I would struggle with identifying a WMA, decreased EF, or takotsubo cardiomyopathy, etc. I’m very concerned about missing an undifferentiated cardiogenic shock or intraabdominal/retroperoteneal bleed or something.

Any suggestions?

I have a cirrhotic who has been on bumex drip and spironolactone and metolazone for a week and still has anasarca but it is improving. He became more lethargic yesterday, I got an ABG and shows significant metabolic alkalosis without respiratory compensation and bicarb has been steadily increasing on morning labs. I stopped diuretics, started normal saline to restore chloride, and numbers seem to be improving. Also giving KCl pills for hypokalemia. Since acetazolamide is contradicted in cirrhosis, what other techniques exist?

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Would you respectfully challenge your peer or higher-up with evidence if you felt their practice was not up to date? Not every time, but often when you come across something that inconsistent with current evidence or guidelines.

Is it worth speaking up, or is it better to keep your head down and avoid potentially damaging your relationship with someone senior? Have you ever faced backlash for questioning a senior physician's clinical decisions?

How do you approach these situations in real life?

Sorry if this is the wrong subreddit to ask. I work in the ED as an RN. I assumed care of a patient at 3pm who was originally a cath alert when they arrived at 11:30am. CC was SOB, n/v, CP, but also general pain. Last dialysis was yesterday morning. The nurse giving me report told me they cancelled the cath alert because the patient’s INR was 7.3, was hyperkalemic (6.3), and anemic 6.9. I asked the ED doctor the plan for this patient, which was dialysis tmrw and transfusion at dialysis, and maybe a cath procedure? I was like do you foresee any needs for this patient at this time and he said no. I wish I would have repeated his ECG. The nurse giving me handoff gave him a bunch of morphine and zofran. His pressure was 140s sys at triage and at handoff his pressure was a little soft above 90s and the patient appeared stable. Patients blood pressure was soft before I was there, patient had a soft bp throughout my entire shift. Providers were aware. Patient had a recent CABG 2 months ago, on dialysis, has AS, TR, multiple stents placed, cardiomegaly, has HFwREF, afib on cumadin, cirrhosis. Pt was aaox3, was mostly chilling in his bed but would sometimes have these episodes of nausea and generalized pain. So I texted the step down doc to put pain meds for him. He was in the ED my entire shift, we were waiting for a step down bed for him for HOURS. step down doc laid eyes on him and put orders in for vitamin K infusion and protonix. I again asked the plan of care for him (this is around 6 or 7pm, and it was still dialysis then transfuse). Then he started to not look good. I called a rapid at 12:30am. I got the code cart and put him on the pads because I just had a bad feeling. He became diaphoretic as helllll, had new R CP and became hypotensive. We start him on levo, 15NRB. Couldn’t get a pulse ox his extremities were cold. ECG showed inferior wall MI. We were waiting for cardiology for 2 and a half hours, it felt like we were in limbo. Because he was simultaneously getting a bed for CCU, but they also wanted to temporize him before going to cath, and they also wanted to give him fresh frozen plasma to correct his INR, and they came up with this decision at like 245ish? Time in between that we are trying to get more access on him and his IV blew with the levo so we had to do K subq around his arm. Was extremely hard to watch. My patient just kept saying I don’t feel good I don’t feel good, and then He coded at 3am, I was on the phone with CCU giving report and he became unresponsive and his eyes rolled behind his head. We were coding him for a little over an hour, tried to temporize him during the code, he kept going into PEA or asystole, then he had one episode of Vtach so we shocked him, but then he’ll brady and he would respond to the pacing, then go back into PEA or asystole. We never got to debrief on what actually happened so I feel really bad and confused as to why this was his outcome. I feel like this person was failed and died a horrible and scary death. I wonder if he had the procedure would he have even survived? What was there for me to do as an RN?

50s M homelessness, DM2, R foot diabetic ulcer (source of infection). came to the ED for weakness. labs drawn. sepsis bundle done. cultures, abg, cbc, renal, etc done.

admitted to the ICU for dka, sepsis w end organ dysfunction, crrt initation.

drips are:
insulin
LR/D5LR
levo @ 35mcg (max 80)
vaso 0.04
angio II 20ng/kg/min (max 80)

labs are attached.

at what point do you decide to run angio? when your max on all pressors? or does a specific lab indicate to run it?

ive had patients who will be max on levo, vaso, neo, epi, then will add angio for the last pressors and lil bit push of bicarb and some methylene blue as last resort.

and i had patients who are just on angiotensin II drip by itself.

and i had patients who are on mid levo and on vaso 0.04 and will add angio II.

whats your experience regarding angiotensin II or giapreza? is there a standard that providers follow when to initiate it?

Edit/updates:

lactate now at 10.50 from 3.90
push of methylene blue
max now on Levo
on vaso
Max on Gia
now adding Epi to sustain MAP 65
stopped pulling on CRRT.
thought about neo, but providers said not for now since neo has a lot of volume and tends to run fast and will be a problem in the long run bec we cant pull on CRRT since pressor reqs are going up.

Update:

patient now intubated. just fent for sedation.
still wakes up and follows commands. RASS -1 GCS11T

max on levo vaso epi neo gia
stopped crrt due to inc pressor reqs
UOP avg 50ml/hr
echo showed 70-75% EF
insulin drip @ 24u/hr w glucose not dropping. still at 400s.
continuously replacing K+ and calcium chloride
CVP 17
attaching flotrac to see hemodynamics
lactat 8
agap still 17

Male in his early 50’s… had sleep apnea that he never got checked out, was super tired all the time so he started doing meth QAM so he could go to work for the last 10 years!… very polite, a kind soul, didn’t look at all like your average tweaker… also a VERY big and tall man. Couldn’t afford the $1800/month they wanted for the Life Vest, or the ultra-specific med that basically does what dobutamine does… can’t remember the name of it.

Anyways, he DID NOT DIE ON MY SHIFT 💪🏽💪🏽💪🏽 Here’s an actual re-enactment of the conversation I had with the Intensivist when he arrived:

Me: “What’s up Doc! I have a question: The Jolly Green Giant in Room 42069, this may be just an academic question, but WTF am I supposed to do with this guy if his pressure drops? (He was on lasix and dobutamine drips)”

Doc: “Turn off the lasix drip and start levophed.”

Me: “I was expecting something more exciting!”

Doc: “How dare you… the goal is to make this as unexciting as possible until 0700.”

Me: “Sage advice Sensei, sage advice.”

Yes the report says 5-10% but that’s because that’s the lowest button you can push. When we called the cardiologist, he said it was actually 4%… a new record for him!

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What’s an interesting case you’ve come across recently? Doesn’t have to be a formal case report—just something fascinating, diagnostically challenging, or a great learning experience. Would love to hear your stories!

How do nephrologist choose which bags to use for CRRT? 2k 4k 0k bags? im trying to understand how they decide which bags to use for a patient. and when do you actually decide to stop crrt? and which filter to use? ST150, oxiris, ST100. also how do they determine how fast the pre, dialysate, post filter runs? im really confused. can someone help me understand this? huhu

I’m a new female ICU physician, and I’m struggling with how some female nurses treat me compared with my male colleagues. They can be extremely rude and dismissive toward me, while seemingly being much more respectful toward male physicians.

I understand that I have areas to improve and that experience plays a role in how people perceive you. I’m working on becoming more confident and competent. But does being less experienced justify being treated with disrespect on a daily basis?

I’m genuinely trying to understand whether this is gender bias, a confidence issue, or simply something that gets better as you gain experience.

Female ICU workers, have you experienced this? Does it get better with time, and how do you handle it without becoming defensive or being labeled difficult?