I don't think a fellowship is necessary. More than anything it is a mindset. It requires an absolute dedication to doing everything necessary to stabilize the sick patient, even at the expense of the well patients who may complain or feel slighted.

Chris, can you clarify your level at this stage and what you mean by breaking in. Do you want to lecture, produce FOAM, simply participate in the conversation, etc.

think these folks are nailing it
http://emed.wustl.edu/educa…

personally I hate small groups (but this may not be a totally pedagogically sound assessment)
I want to hear what everyone has to say. I love the idea of assigning multiple articles in order to find truth rather than just learn how to analyze an article. I like journal clubs where we try to find an answer to a clinical question rather than assess an article. St Emlyn's also kills it.

wow great and tough question. I'll answer for every resuscitation doctor
1. PIOPED I
2. TTM Trial
3. Any of the Croskerry cognitive biases in EM papers

#1 far and away is that it is ok to intubate a patient and then do anything else except give a bunch of analgesia before sedatives

#2 along the same lines, it is ok for a patient to be left in excruciating pain when they are unstable

#3 It is acceptable for any other specialty to dictate how we practice in our own department

Chris, I am the wrong person to ask. My path was a one-off and total happenstance.

easy
1. I was a strict follower of EGDT in 2002 and by 2014 I use none of it
2. 36 instead of 33 for post-arrest
3. Apneic oxygenation is a game changer

bonus: ECMO, ECMO, ECMO

Special K baby. fentanyl as well, see my discussion with Rick Dutton: http://emcrit.org/podcasts/…

hell no. Any resus doc is a palliative care doc. Maximally aggressive care always, whether curative or palliative. the former without the latter makes you a monster

no. we've been doing a version of arise and process for the past 3 years in the NY STOP Sepsis collaborative I co-chair. We have ~22% ARR of death in 15,000 patients.

biggest worry I have right now. FOAM is spoon-feeding of info. It should inspire reading, not doing. I have residency directors tell me that residents are doing crazy stuff and then saying they heard it on a podcast. I think it is a valuable use of resident conference time to review FOAM and see if it translates to the individual program and how to do it

it is coming as the solution to persistent arrest, post-arrest cardiac stunning, and may replace mechanical ventilators entirely. come to our site edecmo.org

trial will be published in the next 3 weeks. 62 pts, no complications, self-controlled. in the critical desaturaters every single one of them improved their sats. no tweaks. just expansion to hemodynamic dsi–give the ketamine first in shock patients to see what it does

come to NYC, we'll school you on the creative uses of language : )

it is a shit-show. let's just get it out there. these conditions should be missed or we should accept an enormous amount of overtesting. Our society should issue a statement that missing PE, dissection (of any vessel), nec fasc, unless the pt presents with totally classic symptoms, should be considered the standard of care

hey brother

xabans get 4-factor PCC, though we don't know if there is in-vivo reversal of the bleeding. Pradax-who knows. Janus general still gives the 4 factor, but I have no idea if it works. FEIBA is probably better for Pradaxa. There will be insanely expensive antidotes for all of them very soon and we will use those.

easiest question in the world. SMACC 2015 in June in Chicago. It will be the best conference in all of resus and I don't get a dime from them. smacc.net.au

My bud Haney Mallemat has a great lecture on this on free em talks.

Biggest tip is good ramping for airway management, changes an impossible airway to a doable one:
http://www.airwaycam.com/Ea…

use a bougie with the first attempt

beyond that, most of them need scans and only a few of them fit. super easy to miss stuff. most need admit even if you can't figure out why.

i think we are failing these folks on the psych end. there is usually an underlying problem and this is just as much a path to suicide as the tylenol od

scares the shit out of me, but I think its got to be me. i can't imagine captaining the ship any other way. but like i said I am petrified. we are supposed to be a real healthcare system and we are treating the situation like amateurs.

In the ED
the post-intubation pt
the demented, elderly sick pt
the neurocritical care pt that doesn't immediately leave the dept

i know my limits and i am not smart enough nor do i have the time to figure this stuff out. all money is indexed

start a peripheral deep vein in the arm or a central line, that's all i do anymore–ej is too sketchy

sure, be right over

it is all modeling and giving them the space to be able to do what's right. i've worked in 3 hospitals and all of them had dedicated staff, nurses, and space solely for the care of the critically ill in the first hours of arrival. without that it is all lip service

there were a few years right after my first fellowship where I started my new job with all of the most cutting edge knowledge of trauma that could be packed into 1 eager skull. I arrived to a group of surgeons (at Janus General) that told me a patient is too sick for the OR, that ATLS is the way we practice, and that ED docs shouldn't open chests. Happily the leadership changed and everything became better, but I hated trauma for a few years. My fellowship was in Trauma Critical Care. If not for the great medical cases I may have had to leave practice at the Janus

you need to read everything you can your hands on. that will do it. everything flows from there. i can tell you the great docs, easily–they are always reading. sine qua non

i use whatever matches best to the patients current acid-base/neuro status. NS is the way to go for brain injury or vomiting patients

: )

RUSH Exam or any exam that gives me an answer to why my pt is hypotensive (FAST Comes in at #2, but i have less i can do with the info)

sick heads don't take a joke. even one perturbation (hypoexmia, bp, hypercapnea) and their chances of survival decrease sharply. these folks need 1:1 nursing an an attending seeing only a small cohort of other pts.

upgrade from what

i've always admired the docs that take their residents back to the bedside after presentation and redo the physical exam in tandem. i am trying to do that more and more. i am also rereading Sapira's the art of physical diagnosis and trying to reintegrate that lost knowledge

my friend Brent Thoma and his colleagues have worked up a schema that should be published shortly. it is the best thing out there

transfusion is easy < 7g /dl. Inotropy if you have given fluids and raised the MAP to 65 and the heart still looks crappy on echo.

always ask yourself if you think the pt has >2% chance of PE. if not and you write that in your note and why, that should be enough to stop. then always PERC. then always d-dimer unless high. still in the running then ct. here is the algo: http://emcrit.org/misc/imag…

when acep states age-adjusted is ok, will do that as well

had a N-bomb patient that continued to get worse no matter what we did. scariest drug out there in my opinion. every organ system shut down.

you need to get the cerebral perf pressure >55-60. i have no problem at all reaching for norepi at the drop of a hat to make that happen

3 ways to get an interview
1. do a rotation at that shop
2. get a letter from someone the program directors know and trust
3. kick ass on the boards

once you have an interview, you must come across as someone i want to drink a beer with or what's the point of having to hang with you for 4 years

what is the world series

i love my boy, my wife, and my friends. the rest of it has blended with my career. i don't advocate this path

i only work critical care, i owe it to my patients to be on top of everything. i think with em residents, they want this level of interaction–the learning opportunities are already too scarce. we're starting a fellowship–that will be tough to find how much leeway i can give the fellows to muck things up before stepping in

can't thank you enough for those kind words

smartest move you can make (nobody ever does this) is to just shadow an existing attending during the night shift for 3 or 4 hours. gives a realistic vision of what your life will be like. med studs do this to decide on 3 years of their life, we go in cold for a potential decade long stint

i guess there should be a description of the thought process for why the ABCs were not maximally controlled if you didn't intubate, secure the airway, etc.

never blame the consultants for stupidity in the record–can get you fired, but make it clear that you advocated maximally for your patient when the fault rests on their shoulders

Tom Scalea is the doc I want to be when I grow up. Peter Deblieux made me want to pursue ED Critical Care. Manny Rivers showed me that Upstairs can be brought Downstairs.

Getting Things Done by David Allen will change your life

bring nurses into every major decision from Day 1. Took me 2 years of fights to figure that out. Any time someone tells you that you can't do something,find a way to show that your pt needs it and have them offer you a valid alternative–most times there is none.

We had an eclampsia case at the Janus where I had to interact with OB, Anesthesia, multiple nurses from other services, and neurology. Everyone worked together, not a single fight or wasted moment. The medicine was not complex, but I left that shift feeling like a million bucks.

it is actually very rare. there will be pts that are crazy hypotensive, but are fine on reasonable doses of vasopressors. in general these pts are markedly less sick and do well post-icu

with VL, you can just tube them sitting up. DSI if they won't accept preox. you can always lie them down once the induction and relaxant are in

can't imagine it. whole purpose of my work is a teaching lab to improve care

substrate? please define terms

as a crit care fellow, the track i placed caused the pt to have a trach-innominate fistula and become brain dead just as he was going to be discharged. we are hard on our surgeons, but they have to live through this stuff all the time. that patient still haunts me. if not for me, he may have gone home to his family

wrong person to ask, haven't found balance. see path to insanity lecture

Triple H seems to have waned. We have found that the best solution to ICP may be to push CPP higher than 60 and see how the pt responds. Individualized goals. Switched to 23.4% hypertonic, and started using NaBicarb instead of NaCl for the lower % administration

not going to unless forced, it is bullshit

i don't discharge in my gig

gotcha. first job for three years is not a bad way to go if you have a family situation that will allow a move. so go mentorship and then the substrate. more shops you see, the better you are (have failed in this regard, myself)

a master lecturer can do 2 hours easy. 20 minutes is better for most. secret to the masters is they would give 6 twenty minute lectures if you gave them the 2 hours and then stitch them together with transitions that make them seamless

Wow, that is tough. I think the tact of, “Gee I just came across this article saying…” and sending that to your co-attendings or other departments and asking, “Maybe we can try this for a few months and see how it works.” may be one way to go.

Or you can go the fight inducing route of doing what you think best and then challenging anyone who disagrees to produce evidence to the contrary. be aware people will be praying for you to fuck up if you go this route

2 new trials just published ahead of print in resus: Cheer and Japanese OOHCA trials. for more we talk about it all on edecmo.org

imaginary hospital. no unaltered pt data ever. be able to back up everything you say with evidence

etomidate's role remains the one that can be taken out before the pt arrives, other than that no benefit.
i like keeping suc and roc around, use the latter 9/10 times

nope, just looked–super interesting

Mike Lauria, ex-pararescue still in med school. Entire resident contingent of SMACC. Met John Greenwood and Jim Lantry while they were doing EMCC fellowship they will be superstars

no limit. pharmacy may impose 250 mcg/hr limit. if you were bolusing with each dose increase, you'll rarely hit anywhere near this. consider supplemental ketamine

with colleagues you trust–like Cliff Reid for me

i want Todd Rasmussen to give me a REBOA lecture.

ask my residents, but i think pretty well

i'll just say one for the rest read Croskerry. We have no perception of how much time goes by while we dick around during a resus. I think you could save many lives if you just had a hired hand who would come up to you and say doc, “That hypotensive pt has now been here 30 minutes,” and “45 minutes” “60 minutes” you get the point. try it during a critical trauma. just announce to the team, this pt has been in the bay 30 minutes what is our plan to move?

umm, I have this podcast called EMCrit