I just wanted to remind you that the term "institutional loyalty" refers to you being loyal to your institution (hospital), not the institution being loyal to you. You are dispensable... #medsky

“There are three stages of scientific discovery: first people deny it is true; then they deny it is important; finally they credit the wrong person” - Alexander von Humboldt (1769–1859)

ICU Snapshots: This is what I don't want to see when a patient on heparin drip crashes:

ICU - Board Review Qs: 60 yo pt admitted to the ICU because of inferior STEMI. Emergency cath: 100% proximal RCA occlusion treated successfully with stenting One hour post-PCI: dyspnea/anxiety - BP: 94/70, HR: 60/min (sinus). Phys exam: JVD (+), clear lungs, cool extremities

I consider Emergency Medicine the most difficult specialty. That said, in a non-mass casualty ED situation, sending to the ICU a septic patient, hypotensive on 2 pressors, anuric, hypoxic, with a Hb of 5.0, lactate 10.0 & K 6.0, w an IO & a non-functioning 22g may be less than ideal

ICU/ED Airway "Secrets": ~40% of endotracheal intubations (ETI) performed in the ICU or the ED result in hypotension, hypoxemia, or cardiac arrest Of all procedures, ETI is the one I find most intimidating & have the greatest respect for #foamed #foamcc #meded #medsky #emimcc

ICU Secrets: If you use the Swan-Ganz catheter as a long central venous catheter, such as monitoring only the CVP value, then chances are that you won’t become much wiser by inserting it… #foamcc #hemodynamics #emimcc

ICU/ED/OR Airway "Secrets": #foamed #foamcc #meded #medsky #emimcc #airways While you attempt direct laryngoscopy in a hypoxemic patient, you get this view:

ICU Stories (at the beginning of my night shift): Me: Anybody coming? Morning ICU shift attending: Just a young patient with etoh withdrawal from 2D The patient 👇: Not responsive. SBP in the 80s, HR: 150/min, breathing 60/min. O2 sat 96% on 15 l/m non-rebreather mask. Febrile

ICU Stories (at the beginning of my night shift): Me: Anybody coming? Morning ICU shift attending: Just a young patient with etoh withdrawal from 2D The patient 👇: Not responsive. SBP in the 80s, HR: 150/min, breathing 60/min. O2 sat 96% on 15 l/m non-rebreather mask. Febrile

ICU/ED/OR Airway "Secrets": #foamed #foamcc #meded #medsky #emimcc #airways While you attempt direct laryngoscopy in a hypoxemic patient, you get this view:

I consider Emergency Medicine the most difficult specialty. That said, in a non-mass casualty ED situation, sending to the ICU a septic patient, hypotensive on 2 pressors, anuric, hypoxic, with a Hb of 5.0, lactate 10.0 & K 6.0, w an IO & a non-functioning 22g may be less than ideal

ICU/ED Airway "Secrets": ~40% of endotracheal intubations (ETI) performed in the ICU or the ED result in hypotension, hypoxemia, or cardiac arrest Of all procedures, ETI is the one I find most intimidating & have the greatest respect for #foamed #foamcc #meded #medsky #emimcc

“Large language models can be unreliable and say dumb things, but then, so can humans” -Blaise Agüera y Arcas

ICU Snapshots: This is what I don't want to see when a patient on heparin drip crashes:

ICU Secrets: If you use the Swan-Ganz catheter as a long central venous catheter, such as monitoring only the CVP value, then chances are that you won’t become much wiser by inserting it… #foamcc #hemodynamics #emimcc

Not a #fluid situation #sepsis #foamed #foamcc #emimcc

Not a #fluid situation #sepsis #foamed #foamcc #emimcc

Right ventricular (RV) involvement complicates >30% of acute inferior STEMIs, though hemodynamically significant RV infarction occurs in ~10–15% of cases. The classic teaching is that when a patient w inferior STEMI becomes hypotensive & has clear🫁on physical exam, the treatment

ICU - Board Review Qs: 60 yo pt admitted to the ICU because of inferior STEMI. Emergency cath: 100% proximal RCA occlusion treated successfully with stenting One hour post-PCI: dyspnea/anxiety - BP: 94/70, HR: 60/min (sinus). Phys exam: JVD (+), clear lungs, cool extremities

We explore the latest Surviving Sepsis guidelines with lead author Hallie Prescott, including the controversies pertinent to US-based practice icuscenarios.com/lightning-ro... #medsky #emimcc

If you are interested in the new surviving #sepsis #guidelines and the controversy around them, you may find useful this podcast with Hallie Prescott, the guideline co-chair icuscenarios.com/lightning-ro... #foamed #foamcc #meded #medsky #emimcc

If you are interested in the new surviving #sepsis #guidelines and the controversy around them, you may find useful this podcast with Hallie Prescott, the guideline co-chair icuscenarios.com/lightning-ro... #foamed #foamcc #meded #medsky #emimcc

He is a good friend but he intubates with midazolam & fentanyl... #foamed #foamcc #meded #medsky #emimcc

He is a good friend but he intubates with midazolam & fentanyl... #foamed #foamcc #meded #medsky #emimcc

In the management of hemodynamics, you may have a different opinion but you can't have a different physiology #foamed #foamcc #emimcc

In the management of hemodynamics, you may have a different opinion but you can't have a different physiology #foamed #foamcc #emimcc

“There are three stages of scientific discovery: first people deny it is true; then they deny it is important; finally they credit the wrong person” - Alexander von Humboldt (1769–1859)

In this retrospective cohort study, dexmedetomidine (DEX) exposure was associated w a HIGHER risk of clinically significant supraventricular tachycardia. Interesting, because I have used DEX thousands of times & I never recall this phenomenon (it happens only after stopping it) 🤷‍♂️

In this retrospective cohort study, dexmedetomidine (DEX) exposure was associated w a HIGHER risk of clinically significant supraventricular tachycardia. Interesting, because I have used DEX thousands of times & I never recall this phenomenon (it happens only after stopping it) 🤷‍♂️

Five big ideas to improve the care of the critically ill patient (by Derek Angus) #foamed #foamcc #meded #medsky #emimcc jamanetwork.com/journals/jam...

#CPR: EMS placing an arterial line (under US guidance) during CPR to guide resuscitation is a gangster move! Respect! #foamed #foamcc #meded #medSKY #emimcc

Vitamin D - A Personal Story: A year ago and during a period when I was feeling exhausted, my Internal Medicine brain module overpowered my Critical Care brain module. This gave me the brilliant idea of asking my primary care provider to check my vitamin D level

Vitamin D - A Personal Story: A year ago and during a period when I was feeling exhausted, my Internal Medicine brain module overpowered my Critical Care brain module. This gave me the brilliant idea of asking my primary care provider to check my vitamin D level

ICU Rounds: I don’t want to brag about myself but 2 days ago I managed *without giving albumin* a septic patient who was on norepinephrine 0.32 mcg/kg/min & vasopressin 0.04 u/min & had an albumin of 1.5 g/dl. Today he is off pressors. Who could imagine? #foamed #foamcc #meded #medsky #emimcc

ICU Rounds: I don’t want to brag about myself but 2 days ago I managed *without giving albumin* a septic patient who was on norepinephrine 0.32 mcg/kg/min & vasopressin 0.04 u/min & had an albumin of 1.5 g/dl. Today he is off pressors. Who could imagine? #foamed #foamcc #meded #medsky #emimcc

ICU Rounds: I don’t want to brag about myself but today I resisted the cardiology team’s request to start bumetanide drip and albumin in a patient with fluid overload #foamed #foamcc #meded #medsky #emimcc

ICU Rounds: I don’t want to brag about myself but today I resisted the cardiology team’s request to start bumetanide drip and albumin in a patient with fluid overload #foamed #foamcc #meded #medsky #emimcc

The evolution of acute pulmonary embolism classification (including the recently published 2026AHA/ACC/ACCP/ACEP/CHEST/ SCAI/SHM/SIR/SVM/SVN Guideline): #foamed #foamcc #meded #Medsky #emimcc

Albumin (A) replacement therapy in septic shock In a multicenter RCT, 440 pts w septic shock were treated w A aiming to keep serum A > 3.0 g/dL or w standard fluid therapy. 90-day mortality did not differ between the A group (43.3%) & controls (45.9%) jamanetwork.com/journals/jam...

Mom of 7-year-old hospitalized with measles encephalitis: "I still wouldn’t have given my son the vaccine" #PublicHealth #Medsky www.independent.co.uk/news/health/...

Mom of 7-year-old hospitalized with measles encephalitis: "I still wouldn’t have given my son the vaccine" #PublicHealth #Medsky www.independent.co.uk/news/health/...

Albumin (A) replacement therapy in septic shock In a multicenter RCT, 440 pts w septic shock were treated w A aiming to keep serum A > 3.0 g/dL or w standard fluid therapy. 90-day mortality did not differ between the A group (43.3%) & controls (45.9%) jamanetwork.com/journals/jam...

In science, the most beautiful theory can be slayed by an ugly fact. In medicine, a beautiful therapy can be killed by an ugly trial

Public Health message:

Obesity hypoventilation syndrome/obstructive sleep apnea (OSH/OSA) - Some thoughts: The following are some issues I have frequently encountered in the management of patients with OSH/OSA (I will intentionally combine them herein for the sake of the discussion):

#Bronchoscopy: Besides setting the peak pressure alarm to its maximum (~100cmH2O), do you use any specific ventilator settings during fiberoptic bronchoscopy (FB) in intubated patients? The VentSetFib study showed that using specific "bronchoscopy-optimized" ventilator settings

ICU Secrets: “If you aren’t escalating care, you should start de-escalating”...

The United States has the highest incarceration rate in the world: nearly 2 million people locked up in 1,566 state prisons, 98 federal prisons, 3,116 local jails, 1,277 juvenile correctional facilities, 133 immigration detention facilities, 80 Indian country jails etc

The United States has the highest incarceration rate in the world: nearly 2 million people locked up in 1,566 state prisons, 98 federal prisons, 3,116 local jails, 1,277 juvenile correctional facilities, 133 immigration detention facilities, 80 Indian country jails etc