@IM_Crit_
@imcrit
Intensivist I Internal Medicine | ☕️, 🍩, 🥐, 🍫 addict #emimcc
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:
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!
2026 has reached the point where "Cannibalism is bad for your health" required scientific confirmation
Some fortunate ICUs have that one aide who knows everything: where every piece of equipment is kept, from gauze to 9Fr catheters to pacing wires; what needs to be reordered; and, just as important, when something should not be reordered at all! They know how to move patients safely, how to calm
In the past, when diuretics were given outside the ICU, creatinine increased and diuresis was held. Creatinine increased from 1.2 to 1.7 while patient was in the ICU but we didn't care and didn't stop diuresis...
ICU stories: Middle-age pt w known cardiomyopathy comes to the ICU from the ward w "fluid overload" after AICD fired once. BP 95/70, HR 90, on 6 l/m O2 (nasal cannula). Anasarca: + Cards asked us to "optimize" fluid status before heart cath. In 2 days, > 22l of urine & >20l (-) fluid balance
The same individuals whose feedback is being solicited have paid substantial fees to participate in the USMLE process. For 2026, the published application fees are $695 for Step 1, $695 for Step 2, and $955 for Step 3, before considering other possible costs such as preparation materials, travel etc
The United States Medical Licensing Examination (USMLE) is co-sponsored by the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME). The USMLE program is inviting physicians to participate in a practice analysis survey that is expected to take ~45 min
Yann Le Cun, former chief AI scientist at Meta before co-founding Advanced Machine Intelligence Labs in Dec 2025 Large language model (LLM) versus a 4 yo child:
Our usual reaction to any new study is either “I don’t believe it” or “I knew it”...... A NEJM trial in ICU pts w acute resp failure found that mucolytics (carbocisteine & hypertonic saline) don’t help. My ICU rounds line “mucolytics are useless” may need an update: “and possibly harmful”
I want to shake everyone’s hand here, but I don’t want my hands getting bruised 🤝 Btw, has anybody heard about senile purpura? Or my Internal Medicine background is acting up?
I thought that routine daily aspirin is no longer recommended for the primary prevention of heart attacks and strokes Please advise
I may be biased here, as I extubate MANY patients directly to NIV when I "feel" they will benefit, without relying on CO2, age, or cardiorespiratory status. This was a post-hoc analysis of two RCTs, and showed that in high-risk patients without hypercapnia at extubation, prophylactic NIV alternating
"Interesting" screening questions before participating in a medical survey: 🤦♂️
An audit of 2.5 million academic biomedical-science papers identified ~3,000 w fake references;, ones that could not be traced to known publications. There were 12 times more publications w fabricated citations in 2025 compared w 2023. 🤦♂️ Topaz et al, Lancet, 407: 1779-81. (2026)
Tell me what you want to prove & I will find you a study! A small study presented at the 🇺🇸 Association for Cancer Research Annual Meeting 2026 suggested that “younger nonsmokers who eat a higher quantity of healthy foods than the general population are more likely to develop lung cancer" #medsky
From: Current Anesthesiology Reports (2024) 14: 446-57. doi.org/10.1007/s401... Just one of the personalized peri-intubation resuscitation approaches:
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
If you chose grade 1 CL or POGO >90%, you need to make sure that you were actually looking at the glottis... In this case, the esophageal opening (E) can be confused with the normal glottic opening (G), thus impersonating it:
The POGO score represents the percentage of glottic opening seen, as defined by the linear span from the anterior commissure to the inter-arytenoid notch. A POGO score of 100% is a full view of the glottis & corresponds to the best CL grade 1 view:
The Cormack-Lehane grading system for laryngeal exposure was first described in 1984 for obstetric anesthesia. The original CL grading system consisted of 4 grades: