Lightning rounds – Critical Care Scenarios

Lightning rounds 74: Inhaled pulmonary vasodilators, with Matt Siuba

Our favorite guest, Dr. Matt Siuba (Cleveland Clinic intensivist and lover of the right ventricle), shares his thoughts on inhaled pulmonary vasodilators: nitric oxide, epoprostenol, and the occasional use of inhaled milrinone and nitroglycerin.

Check out the Intensive Care Academy here!

Lightning rounds 73: How to use AI in medicine, with Harvey Castro

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Harvey Castro, MD, emergency physician and AI enthusiast, shares his thoughts on how we can be using AI tools to support medical care today.

Check out the Intensive Care Academy here!

Lightning rounds 72: How to teach POCUS

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How to like to teach (and learn) POCUS in the ICU.

Check out the Intensive Care Academy here!

References

Oto B, Baeten R, Chen L, Dalal P, Dancel R, Fox S, Lange Iv CW, Baston C, Bornemann P, Dugar S, Goldsmith A, Herbst MK, Kirkpatrick JN, Koratala A, Lanspa MJ, Lobo V, Nomura JT, Pustavoitau A, Senussi MH, Sorrell VL, West FM, Sarwal A. Best Practices for Point of Care Ultrasound: An Interdisciplinary Expert Consensus. POCUS J. 2024 Apr 22;9(1):95-108. doi: 10.24908/pocus.v9i1.17240. PMID: 38681157; PMCID: PMC11044939.

Lightning rounds 71: The story of HFOV, with Brian Cuthbertson

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Dr. Brian Cuthbertson, anesthesiologist and intensivist and lead author of the OSCAR trial, shares with us the fascinating history of high frequency oscillatory ventilation.

Check out the Intensive Care Academy here!

References

The OSCAR trial
The OSCILLATE trial

Lightning rounds 70: Jumping ship for private industry, with Theresa Human

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Theresa Human, former academic clinical pharmacist in neurocritical care and now medical liaison for a large pharmaceutical company, chats about late-career transitions and working for private industry.

Check out the Intensive Care Academy here!

Lightning rounds 67: IV fluids

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We give our general take on IV fluids: when to use them, what to use, when to stop, how to bolus and when to use maintenance fluids, and more.

Learn more at the Intensive Care Academy!

Lightning rounds 66: ED vs ICU with Namita Jayaprakash

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We discuss the interface between ED and ICU and why we have trouble understanding each other, with Dr. Namita Jayaprakash, dual-trained EM and critical care physician, and medical director of her ED.

Learn more at the Intensive Care Academy!

References

The Value — and the Values — of Listening

Lightning rounds 65: Global health with Kwame Boateng

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We learn about how to contribute to underserved communities abroad, with Kwame Akuamoh-Boateng, DNP, ACNP-BC, FCCM.

Learn more at the Intensive Care Academy!

References

SCCM Global Outreach KEG
Want to talk to Kwame about a travel opportunity? Email him at mr.kwameboateng at geemail

Lightning rounds 64: The new Surviving Sepsis guidelines with Hallie Prescott

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Hallie Prescott, pulm/crit physician and co-chair of the recent Surviving Sepsis guideline writing committee, gives some insight into the new document, including a few interesting additions and some points of controversy.

For more thoughts, especially from an EM perspective, Scott Weingart also interviewed Hallie over at EMcrit.

Learn more at the Intensive Care Academy!

Takeaway pearls

The new guidelines suggest/recommend:
- Prehospital sepsis screening, and in systems with >60 minutes to hospital evaluation and the appropriate systems in place, prehospital antibiotic administration. (This is a fairly narrow recommendation that won’t apply to many in the US, mostly rural systems with long transport times.)
- Don’t give anaerobic antibiotic coverage if not suspicious of anaerobic infection
- Target a MAP >65 in most, but in patients >65 years old, target only >60.
- Don’t use qSOFA exclusively for screening; use other more sensitive tools like NEWS.
- Consider SDD (selective decontamination of the digestive tract), the use of targeted local and systemic antibiotics in intubated patients to reduce the bacterial load in the upper GI tract and reduce the risk of VAP. This has a long presence in the literature and is more practiced in Europe than the US, but the data is fairly good.
- Suggest measuring serum lactate, and perhaps trending it, but not necessarily trying to normalize it.
- Prolonged infusions of beta-lactam antibiotics are supported (for subsequent doses; the first dose should still be a bolus) due to reasonably positive data.
- If final cultures are negative, consider deescalating/stopping antimicrobials. (Obviously, this means most patients have already received a few days of therapy by then.)
Other old standards like 30 cc/kg fluid boluses and early antibiotic administration remain. Some are upset about this, as they have been translated into US quality measures (the SEP-1 CMS standard) that invoke monetary penalties when not adhered to—a standard that has caused much headache for EM particularly. But Hallie says: this is a global standard with >25 nations involved, and is oriented around medical realities. Translating it into national quality standards, rightly/wrongly, appropriately or bluntly, is not the business of the guideline group, and is purely an American issue.

Lightning rounds 63: How to be right, with Scott Weingart

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Scott Weingart, ED intensivist and seminal educator from the EMCrit podcast, shares his thoughts on how we should be finding truth nowadays: how to read journals, choose experts, use AI, and resolve disagreement.

Learn more at the Intensive Care Academy!

Takeaway pearls

Scott subscribes to around 60 journals and reads them monthly, meaning skimming the topic index, then for any titles that jump out at him he reads the abstracts, then the actual article for any that still look relevant. He doesn’t recommend doing that. Reading around 10 journals would get you most of the high-yield updates, and you could probably get away with 3–4. It’ll take you about an hour a month.
Read at least the methods and results. The discussion, abstract, and conclusion are mostly a mini-review paper. Ask: is this “generalizable,” meaning applicable to me—my patients, my practice, my questions? Could we implement this here? Ask also how your personal clinical expertise bears upon this (sometimes it’s greater than that of the authors). Finally, ask if the rigor of the paper supports the findings, though you may need to turn to methodological experts here given the complexity of modern studies. (Statistical and methodological experts are available out there, whether in your department or on the internet.)
Signals of confidence, charisma, or “reasonableness” are no longer useful (if they ever were) markers of good knowledge in experts, authorities, pundits, authors, podcasters, etc. In fact, truth-tellers are often less compelling communicators, as they tend to hedge and equivocate; that’s what the truth looks like, not clear messages, the latter of which are often fabricated.
One tool for managing this: seek disconfirmation. When pursuing opinions and expert perspectives, don’t look for those that agree with your prior beliefs, look for those that disagree; that is far more likely to be meaningful and useful data if you’re truly curious about what you’ll find. Even if your mind isn’t changed afterwards, your beliefs will become clearer and deeper. Especially in the current era of algorithms, subcultures, echo chambers, and AI tools that tend to agree with you, you need to actively seek these differing views. You should be able to make the counter-argument to your beliefs better than anyone who truly believes it—that’s when you really understand your own views.
When you find a differing view, rather than engaging knee-jerk opposition, ask why? What is different in their population, approach, environment, etc that leads to a differing view from this reasonable person? If your first reaction is “WTF are you talking about?” try to transition into “Hmm… wtf are you talking about?”
Clinical experience always needs to be thoughtfully integrated into the literature. The subtle lessons of experience are not always studied, and a large study of pooled patients may not address this specific patient’s situation. However, we also tend to overweigh the value of personal lessons, especially when it comes attached to emotional experiences.
A psychological pitfall for educators, and especially modern content creators (podcasters, bloggers, talking heads, YouTubers, etc) is the pull of speaking to create controversy rather than truth. We have lost great scientists and clinicians from the realm of real medicine towards hucksterism by this temptation.
AI today is reasonably good at acting as a medical librarian, i.e. “tell me (with references) the major studies addressing this point.” For this purpose, it is probably better than limited attempts at scouring the literature with PubMed, although all it’s doing is scouring the Internet for commentaries that have referred to the literature, and may therefore miss smaller/less known studies. It is less good at answering specific clinical questions, although it can be a useful idea generator, such as suggesting possibilities for your differential you hadn’t considered… since it remembers all facts, and is good at pattern recognition.
Fight the natural tendency of AI agents to be agreeable by prompting them towards disconfirmation, i.e. “tell me where I’m wrong.” If you solicit agreement or even use a neutral framing, they will tend to roll with whatever you suggest.
When thinking or teaching, you will be more right and righteous if you speak in probabilities or allow the possibility of uncertainty, then if you speak in platitudes. Say you could be wrong, estimate a degree of probability… if you think in certainty, you anchor yourself and can never become more correct with new data.
95% of your decisions should be made in advance, either as shared or internal guidelines, based on your current assessment of our knowledge and how you do what you do. The other 5% will require intensive thought at the time, which is a good thing as long as it’s only 5%, and maybe you can generalize your decisions so that decision will be autopilot next time.
Listen to differing perspectives and opinions from different sources to add qualitatively to your market of ideas, without trying too hard to weigh which is a “better” opinion or source, as this is mostly impossible; with that perspective, you don’t need to worry as much about the validity of the source as long as it’s worth hearing.
However, give very little weight to “voting,” or considering how often you hear a perspective. In the modern era of algorithmically served content, media echo chambers, and self-selecting subcultures, as well as the growing rise of completely AI-generated content in infinite volumes, you are likely to hear many voices that share the same opinion, regardless of whether it’s right or wrong, and quantity of perceived voices may have no correlation to the actual number of people who believe something. In fact, many seemingly different sources are really just echoing or referring back to one original source, not reflecting new opinions. “I hear it all the time/everyone thinks that” is no longer a useful tool for finding truth.