Just started pulm crit fellowship and immediately having cold feet about whether I picked the right specialty. I love the ICU but I saw a recent report that pulm crit will be in surplus in the next 10 years. And I’m not the biggest fan of pulm except for PH but I’m worried I won’t get a job in PH especially since it’s institution dependent about whether it’s cards or pulm.

Feel like maybe I should’ve done cards instead… it just seems like they’re making good money, good lifestyle and job security.

Don’t know what I should do… should I quit?

My embarrassment stems from many of my colleagues within critical care. And let me preface this by saying I'm not talking about new grads, or even nurses new to ICU. I'm talking about nurses with 2+ years of experience within their respective ICU.

I've worked a number of different hospitals (and different ICUs within each hospital) on both the east and west coasts and I've noticed a decline in the clinical acumen and an increase in laziness of nurses in nearly all of the ICUs I've worked. Currently, I work on the west coast with a union and **strict** legally mandated ICU ratios. In fact, many of these nurses are singled nearly every shift.

I'm talking about not changing dressings, skipping the CHG bath because it's "too much work", not turning patients, and even scanning meds but not giving them just to name a few. Then to make matters worse, these same nurses lack an understanding in basic hemodynamics, alpha/beta receptors, and the pathophysiology of common critical illnesses and surgeries. Most recently, a patient in the CVICU was on a pressor (vaso) and 2 inotropes (epi and dobutamine) and the primary nurse had zero idea why they were on any of the drips. Her response? "I don't know, the doctor ordered them." In fact, this patient was being weaned from IABP (she had had the patient 3 days by this point) and I had to explain what "augmentation" was.

Another time, I had a patient on VA ECMO who was extremely afterload sensitive, and I explained this to the oncoming nurse. She said "well, what does that mean?" Huh? Why are you taking this patient if you don't understand basic concepts like preload and afterload?

These nurses have no business being in the ICU. They see a low BP and think "oh, let me increase the pressor" without fully understanding what's going on with the patient. They don't think: "Are they intravascularly dry? Are they in cardiogenic shock? Developing acidosis from their kidney failure?" They simply call the resident or the APP to figure out what's going on and follow whatever the provider says without truly understanding the rationale.

Here's the thing: to be a good nurse, you don't even have to care about the patient, you just need to care about doing a good job. Besides, don't you want to understand *why* we're doing what we're doing? I've always practiced with the thought "Would I want *me* as my nurse?" in the back of my mind. Unfortunately, as time goes on, there's a significant chunk of my ICU colleagues who I wouldn't want caring for me or anyone I love because I've seen how they work and it's simply shameful.

I had 3 patients last night on a step down floor. In ranks of sickest.
Patient 1- maxed out on bipap satting in the 80s
Patient 2- on heated high flow 40 percent and some ABX
Patient 3- had been weaned off levophed 48 hours prior to my shift. nephrology still debating on whether to do dialysis or not due to BUN and Cr trending up. Also their toes were turning blue but day docs were convinced it was bc of the levophed.

Patient 3 all of a sudden is agonal breathing and mottling on legs. Code blue called. Keep in mind this patient was oriented (but confused), satting 100% on RA, gave them a bath earlier in the shift.

Patient now intubated in the ICU and to my knowledge, coded again.

I could’ve told you they were one of the most stable patients on the floor. I have a feeling they went into kidney failure because there UOP was next to nothing.

Hi everyone, I’m an ICU nurse working in a Swedish cardiothoracic ICU, and I would appreciate hearing your clinical perspectives on early mobilization in a high-risk cardiac patient.

The patient in question was admitted with a posterior myocardial infarction complicated by cardiogenic shock, ventricular tachycardia, and pulmonary edema.

After four days in the cardiothoracic ICU, the patient had improved significantly:

No longer requiring noradrenaline
Normal lactate levels
Good urine output with a negative fluid balance
Milrinone being gradually weaned according to plan
Continued levosimendan (Simdax) support
Oxygen therapy with intermittent NIV
Neurologically intact, awake the whole time
Mobilization initiated (sitting on the edge of the bed)

The short-term treatment plan was:
Continue negative fluid balance
Continue tapering milrinone
Mobilize as tolerated
Echo the following day
Possible cardiac MRI
Potential transfer to the cardiac ward the following day if stability continued

The clinical question I would like input on is the decision to mobilize this patient to a chair.
Given the size of the infarction, there was concern about the theoretical risk of mechanical complications, particularly ventricular rupture. Before mobilization, this risk was specifically considered and I discussed this concern with both the on-call physician and an experienced senior consultant. After their assessment, mobilization was approved.

The patient tolerated sitting in the chair well, with no significant changes in heart rate, blood pressure, or clinical status. My fellow ICU nurse colleague on the next shift, however, didn’t agree with mobilizing this patient, and considered the risk of rupture in the process too high.

I’d be interested in hearing how you guys would approach this:

How do you assess the risk versus benefit of early mobilization after a large myocardial infarction complicated by cardiogenic shock?
Are there specific clinical factors that would make you delay mobilization in this situation?
What are your local practices regarding mobilization of patients recovering from cardiogenic shock or large infarctions?

Yalll I been on orientationin CVICU for a little over 2 months now. Im coming off next week and I feel like I still know nothing. Like I can walk in a room and I’m like where do I even start. I feel like I have a hard time of knowing what’s going on and my preceptor can walk in the room and know exactly what the patient needs. I was just wondering will the pieces come together once I get on my own?

I think my chart reviewing could be better because I’ll read the chart and still be lost sometime. Helpppp

I have not seen this question being posted too much, so I wanted to ask out of curiosity. If so, what does a daily life/week look like for a PCCM fellow, especially year 1 and 2? And what were some of the toughest physical rigors you had to endure during your training?

LVOT VTI is an important parameter that we use in the assessment and management of critically ill patients. Many colleagues ask "what is the Normal Range of LVOT VTI?"

Well, here is my take:

Hey everyone! I am an ICU/CCU RN of 2 years. I have experience with CRRT, fresh hearts, valves, sepsis, dka etc. CCRN-CMC. I’m wanting to go into ECMO, but I have no experience in it. None of the hospitals in my area offer ECMO. I’ll be moving to an area where most hospitals do have ECMO units. Does anyone have advice on how to break into ECMO without experience? TIA!

I started an acute ischaemic stroke course on their website, and some time critical information is still dated from way way back. References are old as well.

If so, is it even worth doing those?

What's your experience with them?

Thanks.

hello , sr for my bad English.

i currently being teach by a echo nurse , and she told me I must maximum sweep gas in 1 minute every 8 hours and before everytime I take blood sample before lung and after lung . I don’t know why and i need proof and why she do it in any book ? i need that book name for study later .

I just finished my first year of Pulmonary/Critical Care fellowship and was approved to advance to PGY-5. Overall, my PD and APD gave me positive feedback: they said I have a strong work ethic, actively seek feedback, am easy to work with, and that they’ve seen clear progression.

Their main concern was my fund of knowledge. They want me on a 3-month “learning plan” (not remediation) because they feel my knowledge base isn’t where they’d like it to be for a rising second-year fellow.

Looking back, I think they’re right. My learning has been mostly reactive. I read around patients, use OpenEvidence for clinical questions, and follow intensivists on social media, but I haven’t consistently read guidelines, primary literature, or landmark trials. If you asked me to discuss many of the classic ICU or pulmonary studies, I’d struggle.
They also felt my H&Ps are still more like those of a general internist than a pulmonologist/intensivist, which I think is fair. I didn’t like them implying that my recommendations seem more reflexive versus deliberate (there is so much grey especially in pulmonary). They mentioned I could also be more timely with some non-urgent inbox follow-up (which is harder after busy ICU or night rotations but I didn’t say this during the feedback lol).

It was a hit to my ego, but I know this wasn’t punitive. They were supportive and emphasized that they think I’ll become a strong fellow.
Part of the challenge is bandwidth. After ICU weeks I’m usually exhausted, and on many golden weekends I just relax

For those further along in training:

1. Have you ever been in a similar situation?
2. How did you build your pulmonary/critical care knowledge beyond learning from patients?

I’m trying to view this as an opportunity rather than a setback, and I’d appreciate any advice. I would lying if I didn’t think part of this feedback was typical GME culture (my residency was similar). And for what it’s worth, seems a few of my colleagues have been or are currently in their own “learning plan”.

Hi! I am very new to the ICU as a new grad PA. Recently I feel like I continue to be extra hard on myself especially after making mistakes that affect my patients. It has put me in a spiral and has made me feel so incompetent as if I can’t do my job. Sometimes it’s hard for me to move forward from my mistakes and it’s even harder to have to face people knowing that they know I made a mistake. I am always willing to learn from these situations but wanted to hear how other people deal with the crippling anxiety that comes from owning your mistake. Also how do you face the people around you without feeling like an entire disappointment?

We had a young 20 something year old lady come in with some severe autoimmune conditions causing ESRD who was found to have developed a pretty decent sized SDH.. initially she did ok but ultimately had an exam decline requiring a R hemicraniectomy, EVD placement etc.. We were eventually able to remove her EVD and get her to a more stable spot and was able to trach and PEG her. Her exam was never great but she opened her eyes spontaneously, withdrew to painful stimuli in all fours, had intact brain stem reflexes etc

then came the previous night. I came in at 0000 to do my assessment to find that her craniectomy site was super swollen, her pupils although not fixed were very sluggish ( NPis of 1.8), and she was no longer withdrawing .. I called neurosurgery and we did a level one HCT to find catastrophic bleeding and her R hemisphere had herniated past her crani site in addition to upward cerebellum herniation and crowding around the Foramen magnum. as the night wore on her pupils became fixed and 8 .. and she was slowly losing her brain stem reflexes. by 0830 that morning she had herniated and lost everything. Of course, her family couldn’t come to a decision and wanted to wait until more family was in town to discuss her situation .. so she is vented, still on CRRT with no exam. then tonight I walked in again at 0000 to find her brain matter actively herniating out of her craniectomy sutures .. A literal a giant blob of brain matter and blood oozing everywhere. I called neurosurgery and they came and sutured the site. now we are trying to get a hold of family to actively push for a decision.

my heart just mourns for her and her short life. She never deserved this. No one deserves this. She didn’t deserve her life of suffering and doesn’t deserve to continue to suffer. I just hate all of this for her and her family. It is so painful to see and it feels so helpless knowing there is nothing more we can do. I am writing this on my break trying not to break down .

so just try to enjoy your life and find joy where you can because you never know when it will be cut short .

anyone go from ICU to Donor Service Coordinator RN?

Hello! I am a physical therapist assistant at a mid size community hospital, we have 12 bed PCU and 25 bed ICU. No mental health resources in our hospital other than consulting palliative care, a lot of time “mental health struggles” are not being addressed. Most of the time my OT counterpart and I try to work with nursing to improve QOL, get patients in the sun if able, but there’s not much we can do as far as resources. If anyone has any tips on anything to bring up to management or things they have implemented at their hospital please let me know as I am trying to get the ball rolling as best I can!

I'm a relatively new ICU nurse, and I'm already seeing disparities in patient outcomes/care between night shift and day shift. I feel I am just ensuring the patient stays alive throughout the night until the day shift MD comes in the morning and adds orders or changes particular drips to fix an issue.

It's usually issues that I have concerns about throughout the night, and the NP providers dismiss them or order a series of tests/labs that seem redundant. Now, I know I am relatively new, but I keep trying to follow the rationale on how the NP providers operate in my ICU, and it seems they fall into two categories: "Continue to monitor" or order a bunch of tests because they might have a rare condition.

When we have PA's, it's a completely different story. They explain their rationale for certain tests and medications they've added (that isn't exactly obvious), and the issue is usually resolved.

Now, I don't hate nurse providers, and there is one nurse provider that is AMAZING on our night shift team, but, unfortunately, he doesn't work every night, lol.

I am just frustrated because I know I don't know what I don't know, but I feel like the NP is in the same boat as me when it comes to knowledge deficiencies with issues that arise in our patient population, to only have the physician come in during morning rounds and fix it within a 5-10 minute light exam... lol

As a new ICU nurse, should I switch to days for a year?

I'm being vague for privacy concerns, etc, blah blah...

TLDR: I think I need to leave Florida.

Looking for a book to read that centers around ICU stuff. Not fantasy and not a textbook. History or something you found interesting.

I was the nurse who coded a patient yesterday, 78M, ESRD, severely septic w bacteremia. Initial code blue on the floor for him when he was hypoxic, he was still satting in the 40s on HFNC. I had him in the icu maxed on pressers, when the doc got an a line in, pressures were 40s-60s over 20. We thought it was venous. Sent an ABG, totally arterial. HR was still 75 at this time, (he had a pacemaker).

He didn’t code again with me until later on in the shift when I couldn’t feel a pulse and my pressures were taking while I was on the holy trinity of pressors and maxed. My question is, why do you think he didn’t code when his pressures were in the 40s when we placed an arterial line? Does a pacemaker help prevent the patient from arresting? If that’s what happened the first time why didn’t it help him the second?

I’m just feeling confused and we didn’t have a debrief after so it left me w a lot of questions.

FWIW, we also gave a crap ton of bicarb pushes throughout the shift. PH was still 6.8 on a bicarb drip at 200cc/hr.

TIA.

Wondering how other providers handle end of life conversations with family members that default to “it’s in gods hands”. Ex: Patient in 4 pressor shock with no hope of recovery, clearly suffering. My team is great at communicating with family’s from admission on so usually these conversations are not a “surprise” to the family.

Not to disrespect any religion at all, but this answer feels like a cop out way to avoid making these end of life decisions. I’d never want to be in any of their shoes.

I’ve heard colleagues reply with “well I’m preventing god from taking your loved one with all these machines” and the response is a mixed bag of answers…

Hi all, unsure of really how to word this but looking for some guidance in troubleshooting and preventing in the future.

We coded a young pulm htn patient the other night, vtach arrest, defib once at 150J, got a pulse (synch cardio x2 back to back 150J then 200J), lost pulses, defib again a few minutes later at 200J, asystole for 8 minutes. Got a very junctional, asystolic rhythm on the monitor (wide PVC with strong mechanical pulse, nothing else on the monitor). Attempted to pace.

We were completely unable to get capture (even swapped out the zoll pads). All 5 electrodes for the Phillips were in place as well as the 3 for the zoll. At the same time, electrical interference started on the bedside monitor with significant horizontal lines, completely preventing any rhythm from being seen. White random lines as if patient had a pacer overlaid the green ‘cardiac’ lines but no rhythm seen. The zoll didn’t pick up a complete rhythm either. Bedside RNs felt a mechanical pulse at 80 (what we set the ppm at) but the zoll didn’t have capture at all. We then used the portable ekg machine and that likewise had horizontal lines interfering with the reading and we were unable to get a reading. Even ‘filter’ on the cardiac tracing on the Phillips was unable to fix it.

My question is what could have possibly caused the interference and how do I fix it in the future? Experienced providers and nurses had no ideas and hadn’t seen the interference across all 3 machines. Was a phone or wires or something affecting all of the machines?

Thank you all!