@IM_Crit_
@imcrit.bsky.social
Intensivist I Internal Medicine | ☕️, 🍩, 🥐, 🍫 addict | #emimcc
Reflection of the day: In all my years in the ICU, I can’t recall seeing a DVT/PE in week 1 post-op after open-heart surgery That said… we don't routinely screen, & chemical VTE prophylaxis is often held by cardiothoracic surgery I have to ask: Is the real incidence this low, or
Ezra Klein is probably the most eloquent journalist of our times www.nytimes.com/video/opinio...
Video: Opinion | Christopher Nolan Stared Into Elon Musk’s Soul
‘The Odyssey’ is the political movie of the decade.
nytimes.com
Every time I see a continuous renal replacement (CRRT) order for an ultrafiltration rate of 25 mL/hour, a small part of me dies If we're afraid that the patient will crash from removing 0.4 mL/min, perhaps we should also stop sending blood cultures and morning labs... I am just saying...
ICU/ED Secrets: It’s common knowledge that the more times you inflate the BP cuff, the higher the blood pressure gets
ICU (Night) Stories: 90-year-old admitted to the ICU at 8 pm with complete heart block. Cardiology had semi-emergently placed a temporary transvenous pacemaker just before ICU admission. At 3 am, we found her delirious but triumphantly holding this in her raised right hand:
One of the most demoralizing parts of being an ICU physician is watching a patient fight tooth and nail for every intervention while in our unit, only to abandon it the second they walk out the hospital door. Sometimes even before leaving the hospital!
ICU (Night) Stories: 90-year-old admitted to the ICU at 8 pm with complete heart block. Cardiology had semi-emergently placed a temporary transvenous pacemaker just before ICU admission. At 3 am, we found her delirious but triumphantly holding this in her raised right hand:
ICU/ED Secrets: It’s common knowledge that the more times you inflate the BP cuff, the higher the blood pressure gets
Physical Exam Pearls: In the era of POCUS and CT, I’ll admit I’m not as invested in the physical exam as I once was. Still, a time-tested pearl has served me well: when examining a patient, especially an older one, with possible chest or abdominal pain, do not stop your assessment simply
If you never “treated” pulmonary edema with rotating tourniquets in a desperate situation, you missed the good old days & I can tell that you are not GenX (or a boomer!). We placed (& inflated) BP cuffs on 3 limbs at a time to pool venous blood in the extremities and reduce venous return and preload
ICU/ED/Ward Secrets: In a 45-kg patient with severe COPD, giving 1 mg of iv lorazepam to “help tolerate noninvasive ventilation” may not be the best idea. If available, dexmedetomidine (Precedex) may provide better sedation while allowing the patient to maintain respiratory drive
For every complex (ICU) problem there is an answer that is clear, simple, and wrong. H. L. Mencken
Life in the ICU: My favorite line during rounds is: "This doesn't make any sense" Case in point today from a surgical colleague: "Leave the chest tube until output is <10 mL/day" Fun fact: normal pleural fluid production is ~15-20 mL/day I guess that this chest tube will have to stay for ever...
ICU Procedures: Someone has to say it: I love subclavian central lines, but ultrasound guidance hasn't made the procedure easier for me. In fact, it's still the most technically challenging central venous access I perform. Is it just me?
Homer Simpson Hides in Shrubs
ALT: Homer Simpson Hides in Shrubs
static.klipy.com
Unpopular ICU opinion: When a patient becomes apneic during a spontaneous breathing trial, we often declare that the patient failed the trial Maybe not. Maybe we failed the patient by stopping the trial too soon, before sedatives had worn off and the respiratory drive had a chance to return
If you have a little bit more time, a cooperative patient, and the necessary expertise: The “clean duo”: 1 axillary/subclavian venous line + 1 arterial line Different patients. Different circumstances. Different priorities
When the patient is crashing and/or exsanguinating, speed and access come first The “dirty duo”: 2 femoral lines side-by-side in the groin (typically one venous and one arterial) The “dirty trio”: 3 femoral lines (1 arterial + 2 venous: triple lumen and introducer or dialysis catheter)
Unpopular ICU opinion: Switching from a radial to a femoral arterial catheter often reveals adequate pressure and allows for de-escalation of vasopressors. The opposite can happen too... 😩 Welcome to my life!
In a crashing patient, the best vascular access is often the one you can place quickly, safely, and reliably
ICU Facts: In the ICU, nothing good ever happens at 3 in the morning
ICU Facts: In the ICU, nothing good ever happens at 3 in the morning
When the patient is crashing and/or exsanguinating, speed and access come first The “dirty duo”: 2 femoral lines side-by-side in the groin (typically one venous and one arterial) The “dirty trio”: 3 femoral lines (1 arterial + 2 venous: triple lumen and introducer or dialysis catheter)
Unpopular ICU opinion: Switching from a radial to a femoral arterial catheter often reveals adequate pressure and allows for de-escalation of vasopressors. The opposite can happen too... 😩 Welcome to my life!
"It is difficult to make predictions, especially about the future" -Yogi Berra
Unpopular ICU opinion: When a patient becomes apneic during a spontaneous breathing trial, we often declare that the patient failed the trial Maybe not. Maybe we failed the patient by stopping the trial too soon, before sedatives had worn off and the respiratory drive had a chance to return
ICU Procedures: Someone has to say it: I love subclavian central lines, but ultrasound guidance hasn't made the procedure easier for me. In fact, it's still the most technically challenging central venous access I perform. Is it just me?
Homer Simpson Hides in Shrubs
ALT: Homer Simpson Hides in Shrubs
static.klipy.com
Life in the ICU: My favorite line during rounds is: "This doesn't make any sense" Case in point today from a surgical colleague: "Leave the chest tube until output is <10 mL/day" Fun fact: normal pleural fluid production is ~15-20 mL/day I guess that this chest tube will have to stay for ever...
One of my ICU rules: Venous access saves lives. Arterial line gives data I have never seen a patient die because an arterial catheter wasn't placed promptly. I have seen plenty of patients getting hurt (or die) because reliable venous access came too late (or never)
2026 has reached the point where "Cannibalism is bad for your health" required scientific confirmation
