r/IntensiveCare

Current IM resident at a crossroads in choosing which fellowship I want. I like many things about critical care, but I don't know if I can handle the futility day in day out for the rest of my working life. I know for certain I don't want to work in academics (pay is too low), and my understanding is community ICUs get all the trach/peg LTACH type patients who have no hope and all the interesting cases are transferred out. I really do not want to have most of my census be those kinds of patients. If I wanted to do palliative care for most of my day I would be doing a palliative care fellowship instead.

Given that community MICU probably isn't something I would want to do, what else is there that doesn't pay academic rates? The specialized ICUs are all in academics and they seem to prefer non-IM trained intensivists so it's doubtful I'd be able to get a job there. There are a few larger non-academic hospitals around me who have specialized units, but they pay the same as academics based on their job postings.

idk how to distinguish them on ECG...😭😭

hi!!

one of my good friends at work is leaving for crna school in a couple of weeks and i wanted to send her off with a gift she’d hopefully like or find useful.

for those of you who are NA residents, what do you find to be useful or practical?? i’m thinking study aids, self care basket, gift cards??

thanks in advance :)

Curious if anyone has experience doing vascular access with this unit. My facility just got one of these and it seems like there's some latency from the probe being manipulated to the movement reflecting onscreen. It reminds me a lot of those wireless ultrasound setups for a phone/tablet. I recognize some delay is inevitable but it feels just bad enough to throw me off. We normally use a GE venue go in critical care and I feel like its way more responsive. I disabled the cue needle guidence feature since we dont have the extra equipment to use it and that helped slightly. Just curious if anyone else had this issue or its all in my head lol.

I am a third year USMD student who just finished a Neuro ICU rotation and I loved it. I love the rapid changes in status, the complexity of the patients, the acuity of care, and extubating people is so rewarding. I have strong ties to my home Anes dept and am a fairly competitive applicant, am not sure if I love the brain enough or frankly am smart enough to just do straight neuro for residency, i am not sure I would want to do a fellowship after an Anes residency simply because it is a near-surgical workload at my program, I don’t know anything about EMCrit and I don’t really like the lungs lol. I am just looking for guidance and advice, as well as why people took the paths that they took.

My coworker died and I can’t believe it. I still feel like this might be a terrible dream.

We coded him for over an hour, pulled out all the stops, did everything. I feel confident our resuscitation efforts were more than complete.

What’s get me- is that I didn’t recognize him until we had been doing CPR for 30 minutes. I am a critical care pharmacist, I got called down to the ER when CPR was started. He was just another patient until I the nurse read his dad’s name off the chart as an emergency contact. I immediately connected the dots and was shocked. He was so young. He was alive when he got to the hospital.

I had to call our boss to inform her of his death. He is supposed to work tomorrow. He is the only pharmacist in his specialty at our hospital. The community will suffer.

This is crazy. I don’t know how to process this. I’m going to reach out to our employee assistance program tomorrow, but things will never be the same in our pharmacy. These are the things I never thought about when starting this job in a smaller community hospital. This is the second time someone I know has died in front of me.

Just wanted to get this off my chest.

I'm a hospitalist and recently had a patient with generalized weakness and back pain who ended up being profoundly septic. Had elevated BNP and lower leg edema so I thought it was heart failure. No fever, leukocytosis, tachycardia. The emergency department doctor didn't think it was sepsis, the admitting hospitalist didn't think it was sepsis, and I didn't think it was sepsis the next day when I got him. We got an lumbar MRI that the radiologist didn't read as possibly infection. My initial plan was diuresis and then spine surgery consult because there was some cord impingement.

The afternoon of the first day I got him, he got transiently encephalopathic and I thought poor perfusion of the brain and still didn't think it was sepsis. The spine surgeon looked at the MRI and thought maybe abscess and then only did I get blood cultures, even though I wasn't convinced. MSSA.

Patient only started having fevers, rigors, tachycardia about 24 hours after starting antibiotics. Was he just so sick that his immune system couldn't mount an appropriate response until the amount of circulating bacteria was reduced by antibiotics?

Hi!
I have been a nurse for one year now in an 8-bed MICU in a rural, community hospital. I recently accepted a job in a 29-bed MICU in a huge level one trauma center, academic hospital.

I am starting to feel pretty anxious and ridden with imposter syndrome. I am worried that this change will be extremely overwhelming and make me feel like I'm "starting all over" in terms of my nursing career so far.

In my current job, I feel confident in my nursing role and the level of autonomy I have. I feel competent in the basic ICU nursing skillset (e.g., managing drips, ventilators, etc.) but do not have experience with more advanced therapies, including CRRT. Also, my current ICU is managed by one hospitalist, who also manages the medical unit's patients. No intensivist or medical residents/fellows. The place I am going is managed by a formal critical care team, so this will also be a learning curve for me.

So, I was looking to see if anyone here had any pointers for this transition. I will get a pretty extensive orientation, so that is definitely a plus. Thank you all in advance

I’m currently in an ICU, unfortunately my mother isn’t going to make it. The team here has been really kind and work long shifts. Is there something generally that goes over well? Are there restrictions? Thanks.

Newer ICU nurse here trying to get better with morning rounds/provider communication. How do you guys compress info when like 4 different teams are following the same crashing patient? I feel like I end up saying too much because my brain is trying to explain the whole picture instead of just the main concern/trajectory. Just trying to cut the noise and make communication easier for everyone.

I just got told that I will be getting my first capstone student next month and I have never been a preceptor before and we don't have any type of preceptor program at my hospital. I do feel slightly under qualified, I only have about 2 years of ICU experience.

I am just wanting them to have the best possible learning experience. I was thinking of creating some type of "Introduction to ICU" capstone friendly packet for them, would anyone have anything similar and mind sharing ideas?! I would really appreciate it! Or even ideas of things I should include as resources and stuff to go over during downtime if we have any!

thanks in advance! 🩷

Outside of CT surgery protocols, if you have a vfib arrest, VT, or other shockable arrest? Are you all doing the standard ACLS shock x 1 or are you going straight to defibrillation x 3? If so what are your caveats? Also anyone out here shocking asystole without a POCUS to rule out vfib?

Edit: I am not doing any of these things except ACLS within reason

Hi everyone,
I’m an anesthesiologist looking for a portable handheld ultrasound mainly for OR work and on-call interventions. I’d be using it mostly for vascular access, difficult cannulations and regional anesthesia blocks, but also for quick bedside assessments during calls and occasional focused ICU/POCUS exams.

I have been looking mainly at the GE Vscan Air SL / CL and the Mindray TE Air e5M, but it’s surprisingly hard to find real-life long-term experiences from people actually using them daily in anesthesia or critical care.

Has anyone here worked with the Vscan Air SL, Vscan Air CL, Mindray TE Air e5M or maybe another handheld device you’d recommend instead? I’d really appreciate any opinions regarding image quality for nerve blocks and vascular access, battery life and overall workflow in everyday OR/ICU use.

Thanks a lot!

Hi all!

I am precepting a new grad nurse and we were going over what happens during codes. We touched on ambu bags and “bagging” a patient that’s vented during a code. My question is, how would you best explain in depth why we choose to bag someone vs just keep them on a vent? I want to make sure she fully understands when it’s appropriate and when it’s not.

TIA

Just need to vent a bit about a recent ICU case that has been weighing on me.

I took signout from the day fellow on a late ICU transfer from the hospitalist service. The reported issues were pancreatitis, EtOH withdrawal, and euglycemic DKA. The day team was still working on admission orders, and the note when I came on. Initial labs were notable for K 7.9 and lactate 9, which were both downtrending. He was started on an insulin infusion and some fluids. At the time, he was not overtly in shock and was maintaining his BP.

As the night went on, his potassium only minimally improved — from about 6 pm to 3 am, it stayed around 7.5. He had made only ~50 cc of urine during that time (200cc about 12 hours earlier). At that point, it seemed increasingly likely he would need CRRT. I tried a furosemide stress test near the end of my shift with 160 mg given what appeared to be intrinsic AKI, but it failed, which, honestly, was not surprising.

When I signed out in the morning, I told the day team that nephrology needed to be called first thing for dialysis planning. About an hour later, he was intubated for worsening lethargy and started on pressors. CRRT was eventually started, though not until later that afternoon.

When I came back the following night, he was profoundly ill.

The thing bothering me is that I did not more aggressively interpret the hyperkalemia and lactate as early shock physiology. I anchored too heavily on the initial signout diagnosis of DKA/EtOH withdrawal/pancreatitis and attributed a lot of the metabolic derangements to that. In retrospect, his beta-hydroxybutyrate was barely elevated, and the persistent severe hyperkalemia plus worsening acidosis should have forced me to step back and reconsider the whole picture much earlier.

My attending told me this was not some catastrophic miss like ignoring someone actively peri-intubation on HFNC, but said it was “borderline,” which honestly felt fair.

Looking back, the biggest issue was cognitive offloading. I trusted the rushed signout too much and mentally categorized him early, which made me focus my energy elsewhere in the unit instead of continually reassessing why this patient kept getting worse. The warning signs were there. I just did not synthesize them appropriately enough in real time.

Thankfully, the patient is now turning the corner on day 3. But this case has been a pretty painful reminder that shock physiology can declare itself metabolically long before the blood pressure drops, and that severe persistent hyperkalemia/lactic acidosis deserves a much broader differential than “it’s just DKA.” I don't think I have had this bad of a miss since the start of fellowship, and I wonder if I had gotten this patient as a straight ER call for me to evaluate without any previous anchoring, I would have done things differently.

Hey!

I’m a CVICU physical therapist and looking for opportunities to work in a CVICU nearer the DC area. I really love (and specialize) in working at pts on ECMO and heart transplants. I’ve heard that the MedStar hospital in DC does a lot of those cases.

1. Anyone have experience in that icu with the rehab teams?
2. Anyone know how the rehab teams are divided up? My current hospital has a specific cardiac team but I know places like Hopkins have a “surgical” team which is a bit broader than I want

Over recent years there has been more and more research that has come out regarding post-intensive care syndrome (PICS) which is a condition ICU survivors face, which includes symptoms like depression, anxiety, PTSD, and even gaps in memory. There aren’t many interventions that have been proven to manage/prevent PICS. However, there is literature that supports the use of ICU diaries to track the patients course, celebrate milestones, and help humanize the care they receive. My unit is working to implement ICU diaries, but we want to do it right, and we want to make sure it’s sustainable. I was wondering if anyone has any experience utilizing ICU diaries, and would be willing to share how it works in their unit, the successes, and the failures.

hi reddit completely random and also don’t even know if this is a good place to post but im desperate. I’m a nurse in ICU been working here for a little over a year post grad. Everything good but one thing i just cannot seem to get my ergonomics right. As u may know we have q2 turns on lots of pts, also have lots of pts who tend to be bariatric. I always seem to strain the muscles in my back and always have an achy back at work. Luckily nothing that seems too serious and tend to go away when i get off but i don’t want to to continue and lowk thinking about leaving just to save my back (mother is a nurse of 35 years with chronic back pain from nursing so she fear mongers me a lot for good reasons). i’ve asked many people and tried so many options but i can’t seem to get how people “turn with their legs” when there is so little room. Anyways any advice at all would be appreciated to spare a young nurse. Thank you so much for all yall do :)

Hi everyone,

I’m an ICU nurse currently working on a project focused on improving the care for potential organ donors and supporting their families throughout the donation process.

I’d love to hear what other sites are doing well in this area. For example:

- Do you have any unique practices or supports in place for families of organ donors in your ICU?
- Does your site offer any nursing-specific education or training around organ donation that you’ve found particularly effective?
- Have you incorporated simulation, debriefing, mentorship, family follow-up, memory-making, donor honour walks, or anything else that has made a meaningful impact?

I’m looking for ideas that could potentially be adapted into practice at our site, especially approaches that have helped families feel safe and appreciated, and nurses feel more prepared, confident, and supported in these situations.

Would really appreciate hearing about your experiences, successes, or even things that didn’t work well.

Thanks in advance!

I am wanting to update our communication boards for our vented patients. We have a few different ones but they are overly detailed or hardly anything. And honestly the detailed one is too small. If you don’t mind sharing yours it’d would be greatly appreciated. I’m not looking to copy but just looking for ideas to expand upon. 😅 TIA