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”.

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 .

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?

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!

anyone go from ICU to Donor Service Coordinator RN?

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!

Has anyone done CCM fellowship after Neuro ICU fellowship (post IM residency)? Is it 1 year or 2 years? What was overall experience?

Okay so I am a tech on a med-surg floor and our walls only have 1 suction system per room and we got an ICU pt who needed trach suctioning and a purewick. There were talks about getting a urine sample and a sputum sample and every shift so far, they had put both the purewick and trach suction into the same canister.

They previously had this rubber/plastic piece that divided the single point on the canister, into two so that they could connect both of the tubes. So, I got replacement canisters and tubing and moved that divider piece to under the actual suction and was able to connect both of the canisters to the suction.

They both were suctioning as they were supposed to and now we are trying to figure out what these are called and where they came from so we can order some for the unit. I’m also going to post this in a RT subreddit because respiratory was also seeing him and they may have been the ones that brought it.

Does your unit prone patients without paralysis routinely in ARDS? Perceived benefits of same?

Hi all, RN here. When I was just starting in ICU, our pulm crits harped on “good lung down” for improving aeration in patients with pneumos/empyema/etc (regardless of thora/chest tube placement). At a new region I am currently working at, when I utilize this teaching in my practice, colleagues kind of look at me funny/correct me. I have also had situations where good lung down does the opposite(I am aware other factors are always at play) So I guess what I’m asking is, have I been taught wrong? I want to know so I may change my practice going forward. Thanks in advance

Hi, I (27F) have been a critical care nurse in a mixed, mostly medical ICU for two years now and I just recently obtained my CCRN. When I first graduated I had my sights set on CRNA but when I actually shadowed a couple I found it boring compared to bedside nursing. It's a cool job, don't get me wrong, it's just not my cup of tea. I then thought about being an AGACNP but honestly there is a ceiling to nursing. I love nursing and how it is structured but at the same time I wish I had more time to sit and think about my patient's pathophys, clinical condition, and determine a plan of care. Of course this is part of being an ICU RN in general but I feel like its just not enough for me.

I've asked a couple of my intensivists and even hospitalists what they think about DNP vs MD and I've gotten varied responses. Some told me to enjoy my life and go DNP route, that they would never want their kids to be doctors, some are pretty gung ho about the MD route, most are realistic about what it would take and the difference between the two. I'm posting here for the same reasons, really. If anyone has any experience being a DNP, RN to MD, or even just plain MD I would love to know what you think and what your experience is like.

EDIT: I know for sure I'd love to be a critical care doctor, ICU is my first and only love, I wasn't willing to consider any other specialty as an RN and I wouldn't consider anything else as an MD

I travel to different ICUs around the US, and I occasionally take LTAC contracts. What I’ve noticed is the glaring disparity of respect I receive depending on which role I’m in. When I speak to physicians when working in an ICU setting, they normally take into consideration what I say and if they disagree then they will explain why. On the contrary, physicians in the LTAC setting do not seem to have the same rapport with nurses.

I’ve also noticed that colleagues (other nurses) generally do not have respect for the work that LTAC nurses perform. Is it an issue of understanding? LTAC is high acuity, high nurse to patient ratios. It takes a lot of dedication and knowledge for nurses to work in the LTAC environment.

What are your thoughts? If you haven’t worked in an LTAC, what is your understanding of what the work entails?

I could only visulize my needle tip 2/5 a lines that I did.

I ended up mixing up sliding the probe with fanning and got lost couple of tines.

What is the recommended approch specially for shallow vessels within 0.5 cm depth.

​

Do you make the poke and slide your probe to see the tip or fan towards you ?

https://doi.org/10.1016/j.cmi.2026.02.021

I thought maybe this would be appreciated in this sub. For the record, no drugs ended up on the floor!

I'm sat in a safety meeting currently reviewing Ambubag provision. In my nursing career (30 years) I'm used to having an Ambubag in each patient room. Other nursing directors are reporting the same thing. Our supply director is proposing keeping 1 Ambubag on a code cart for the entire floor. Are you guys used to keeping an Ambubag for each patient? Edit... Units are ICU and ICU stepdown.

Thanks

You're admitting (sorry) a patient from OR. Tubed, prop, levo, vaso, random bags of fluids Y sited into no where specific, SWAN and a-line, all tied together in a clusterfu-- bowl of spaghetti. Nothing is labeled. You have to unhook them from everything OR so they can take their monitor and tram back and hook them up to your stuff. The usual. Where do you start on your spaghetti? What are your methods/priorities? Infusions or monitoring? You are allowed to set up all of your new lines before they arrive.

It takes me like an hour where it takes my coworkers 5-10 minutes to get everything where I want it so I'm asking for advice on how to do it more efficiently.

Hi, I wanted to see your guys input on whether I’ll have a difficult time finding an ICU job with 1 year of experience as a Cardiothoracic Surgery Stepdown Nurse. I plan to apply to jobs in California and other west coast states but I heard it’s really difficult without any ICU experience. What are your guys thoughts and experience?

Curious about what the rapid RN role entails in other hospitals. In ours it is not its own position. We are still staff ICU nurses who have to work the bedside 1-2 times a week alternating with the rapid role. Besides rapid responses and code blues, we do the code blue documentation with debrief. We are the sole members who respond to in-house stroke alerts with the occasional appearance from the neurologist. Respond and run the rapid infuser during all MTP’s from the ER to the OR. USPIVs when none of that is going on and to help catch up with breaks in the unit. Also we do not get a differential for that role. Despite having to attend annual education for all speciality equipment. CRRT rotoprone IABP Ceralink/EVD’s Impella, and TTM devices.
What’s it like at your place?