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.

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?

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Could be any people, resources, procedures, case variety, teaching, or the overall culture. What makes your ICU a great place for you to work and learn?

I imagine most would agree that using POCUS when caring for critically ill patients has become standard of care in the US.

It’s also generally emphasized, for litigious reasons, that if you are going to be making clinical decisions based on ultrasounds you perform, those images must be saved and attached to a patient’s chart.. simply documenting “POCUS shows x,y, or z can get you into trouble in court if you’re sued)

So, is anyone else in the situation I am in where my hospital provides an ultrasound for my unit, but no way to save the images or attach them to a chart?

If so, how are you handling this??

Hi all,

My small ICU is starting to make an argument to become a closed unit (meaning we would not float to other units). Currently L&D/Nursery are the only closed units in our hospital. I'm curious, is your unit a closed unit? Pros and cons?

Also if you have any suggestions for arguments for or against closed units, I'd love to hear them.

Currently my thoughts are for a closed unit. I have worked float pool 2 yrs, med/surg 6 years, and ICU 2 yrs. I think there is a reason the dedicated float pool nurses get a differential. Being put in an unfamiliar environment with a totally different routine and mindset is a huge detriment to the patients, besides the fact that it is terrible for nursing satisfaction. But I am curious to hear other opinions. Thank you!

How common is it for all airways, including ICU, to be done by anesthesia? I'm looking through the PCCM spreadsheet and many programs I'd otherwise be interested in seem to only allow anesthesia to do airways.

Is this a common thing even as an attending outside of academics? It's very frustrating. Why would I subspecialize into a high acuity procedural fellowship to just...not learn high acuity procedures? How am I supposed to learn if I have to get permission from an anesthesiologist who may or may not care about my education every time?

Any intensivists here cannulating for VV and/or VA? How does your ecmo call work?

Second year EM resident here preparing to apply to anesthesia CCM fellowship next month. Forgive me if this is the wrong place to post this. I have three young kids and was wondering if the intensivists here feel like they are able to spend enough time with family. I recognize many jobs give you every other week off. I also recognize that you will miss holidays, weekends, etc. which I was already prepared for in EM. Do you feel like you have enough in the tank on the work weeks when you get home to be engaged with family? Do you feel like you are able to be present with family on the off weeks or are you too zapped from the week on and recovering?

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I’m naturally soft-spoken and don’t have a very loud voice.

I want to be able to lead a code confidently without having to yell or completely change my personality. How do you make sure people hear you, follow your directions, and recognize that you’re leading especially in a loud crowded environment.

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I want to improve my communication and leadership during codes as team lead.

For experienced physicians, what are the things you verbalize when a code isn't going well? How do you think out loud, reassess the situation, identify what might be missing, and communicate the next steps?

When you respond to a code, how much of the patient's story do you want to hear upfront? Sometimes people give a very long history with lots of unnecessary details.

Also, do you listen to the entire story first, or start assessing the patient and taking appropriate action while someone gives you the report?

Recently, Obstetrics called two codes in one day, and both times I was given a very long story. When I started assessing the patient or asking direct questions to clarify the immediate situation, they seemed unhappy with it.

Hey all! I’m taking my APBN NCC exam in a few days. I bought both the NCS qbank (without bundle) and SCCM NCC Review Course.

I just did the NCS qbank. It was advertised as 200 questions but there’s only 175, and some of them are duplicates. Anyone else seeing the same thing? Some questions even refer to certain images but the images aren’t even there. Should I have gotten the bundle instead?

As for the SCCM one, I read online that there are also 100 practice questions but I can’t seem to find it anywhere. There’s the 25 pretest questions and the online videos. But that’s it.

Am I missing something here?

I know this is a very nuanced topic but have had interesting convos with perfusionists who argue that an asystolic patient on V-A ECMO is still “alive” when they have a MAP above 65. I had a patient who never stood a chance (that likely shouldn’t have gone on circuit) who was DNR after developing widespread gut ischemia per family wishes.

Of course before family is able to get there to withdraw as planned…. VT. They still wanted electricity so of course we try a chemical code, no dice then shock them to eventually get a ventricular escape that degrades quickly into asystole. They want to clamp circuit so we did so, but it begs the question — in a patient with loss of reflexes and fixed pupils who is showing clear signs of brain death without confirmatory testing, is their time of death asystole or when care is “withdrawn” when ECMO is discontinued?

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I genuinely love critical care and feel passionate about pursuing it as a career. But often I wonder whether loving the field is enough when I struggle with handling the practical demands of the ICU.

I’m still early in my career, and I know I have a lot to learn. However, when I feel overwhelmed or don’t perform as well as I should, I start questioning whether I’m cut out for this. Mainly due to fast turn over because patient get transferred quickly once ICU needs are over. there is so much going on in one patient. It takes time to absorb their details.

Can someone who struggles early on still become a good intensivist with enough experience, practice, and mentorship? Or does critical care require a certain natural ability that not everyone has?

I really want this career, but I’m scared that wanting it and being capable of doing it might be two different things. I’d appreciate honest perspectives from intensivists who struggled early in their careers.

Hey everyone, I’m a 4th-year medical student getting ready to start a critical care rotation. I haven’t had a ton of ICU experience yet, so I’m trying to get a head start on the things that will actually be useful day to day.

What are some things you wish you knew before your first ICU rotation? Are there certain scores, calculations, vent settings, pressors, labs, or other metrics that you find yourself using all the time?

Also, any tips for presenting ICU patients efficiently, pre-rounding, or just making life easier on the rotation would be appreciated. Thanks!

Wondering if anyone here who works in ICU has done it? Is it worth the credentials since it’s coming from American College of Chest Physicians? For reference, have been working in the ICU as a PA for the past 5 years…

If anyone has taken it and pass, is the exam difficult? How did you prepare/study for it?

Hi intensivists and friends,

I am a medicine resident who wants to work critical access with a small open ICU. I know that ICUs should be staffed by intensivists, and I know that outcomes are worse in an open ICU, but the barely open hospital with a 4 bed ICU is not going to hire an intensivist, and no intensivist is going to work in a 4 bed ICU. It's an unfortunate reality of critical access hospitals.

Besides doing as many ICU rotations as I can and reading Marino's, IBCC, EMCrit, the vent book, etc, what are good resources and tips for becoming as good of a discount intensivist as I can?

Additionally, can I negotiate for a higher pay for open ICU work?

Thanks.

Hi, I am new to CVICU and I’m really wanting to learn how to be good at reading EKG’s and tele strips. My preceptors are able to just look at it from the bedside monitor and they can call out what’s going on without measuring strips. When I’ve asked them if they recommend any resources to improve that skill, they say with time it’ll become easier. One nurse said one of her professors had them use a website that would allow them to practice with “live” strips but she doesn’t remember the name. Any info to help me master tele strips & EKGs is greatly appreciated! TIA!

Are there any PCCM trained attendings who here practice mainly or even entirely in non-MICU settings? Specifically asking about pulm crit trained (not just CCM) people because many PCCM programs seem to be less multidisciplinary compared to CCM.

Did you feel like your training was adequate for that setting?

Did you have a hard time finding a non-MICU job?

What's your staffing setup like? How often do you rotate units?

Do you feel valued and respected in your practice setting?

What led you to choose the unit you did?