r/IntensiveCare

I'm at a community hospital in a impoverish area. We had around 14-16 patients in the unit. Most of our patients are very sick at baseline, 40-year-olds and 50-year-olds on dialysis. We get a lot of post-arrest patients, HD patients maxed on pressors who need CRRT now. Occasionally, we have a pt on CRRT and balloon pump. Our devices are always a 1:1 assignment. We see a lot of sepsis, trach to vent patients from LTACH. 50-70% of our patients are on dialysis. We see GI bleeds, post-arrests, COPD exacerbation, and respiratory failure, DKA, and liver failure, typical MICU. Last week we had 4 code blues. But sometimes our acuity does go on the lower end like patients who only need 5 mcg of levo. Just wondering how high this is compared to other ICUS?

I want real and honest feedback. I applied for an icu educator job at a large level 1 trauma facility and actually got it (NYU). Honestly, I was so surprised but they moved quick. screening call and 3 interviews and job offer in 9 days.

however, I am a little worried I don’t have enough experience….I am a covid nurse so I do think that surviving that baptism by fire made me much stronger than an average new grad after one year than what would have been the case prior to the pandemic.

I did that first year of cardiac stepdown at a busy level 1 trauma before moving to a medium acuity facility where I was in MICU/CCU for 2 years then SICU/CTICU for another 2.5. I do also have Rapid Team experience as charge nurse is always rapid response on these units

About a year ago i started teaching as a crit care educator at another level one trauma center on a per diem basis. I teach critical care skills like PA cath floating, art lines, setups, iabp, as well as generic RN ICU orientation on didactic topics such as EKG, cardiology, neuroscience, respiratory, pulmonary, GI and multi system.

These skills I am comfortable with - but I am lacking in experience such as Impella, ECMO, CRRT (my facility had an on call dialysis nurse, spoiled I know) and stroke stuff. My bedside gig was not a comprehensive stroke center.

Does anyone have any advice or thoughts? I’m also welcome to honest opinions even if they may not be the most positive. I like to say I am pretty well read on topics as I studied from books such as “Vasopressors and Inotropes” and have my CCRN-CMC, but still feel like I am lacking or may have a knowledge deficit when starting this role

I just accepted an offer for an ICU position as a new grad APRN. Most of my background is in ED, so I am looking for guidance. Are there any apps that people recommend or specific resources I should look up? I am a member of AACN and will be looking to see what resources they have for new APRNs.

Hello,

I was wondering if someone could fill me in on which incontinence products are used in the ICU and/or how they are used. Do you you guys use any briefs, pull-ups, chux, and/or small urinary pads/liners?

Thanks!!! 🙏

I kind of just wanna rant on about my experience while in the ICU & if anyone has some crazy stories. I was diagnosed with leukemia in 2017 to 2020. In between those, I was in the ICU twice. To this day I have no clue why, but I remember complaining because I couldn’t breathe so they took my blood pressure & my HR both of which were incredibly low. I got sent to the ICU & I don’t remember the actual real world. Here’s what happened in my brain

I was in the ICU, but I didn’t know that I was in the ICU. I was just there. They didn’t let me drink anything at all & I remember being so thirsty for sprite. They let me have these pink little sponge sticks that you can soak in water & suck on to ‘drink’, but I wasn’t allowed a lot of those. I asked my mom (she took care of me) if I can have one & she gave me one. I asked for another & they refused because I already had my max for the day. I also had a catheter & there was also some biopsies they did on my skin. I had to have oxygen hooked up to me & I don’t know the rest (some of this is from my memory, others are from what others told me)

In my head here’s how it went:

I want the pink sponge because I’m soooo thirsty. I finally get one & they won’t give me another. I can’t believe they only gave me one strike. I can’t get three strikes or they’ll put me in prison when I’m already in jail. They really put something up my v*a*ina I can’t believe someone did this why would they torture me. Oh that’s my mom let me tell her to make them stop. Heyyyyy!!! Tell them to stop!! How come you’re ignoring me! You’re just going to let them do this hey listen! I’m trying to call you! (She was standing looking out of a window from my recollection of this). Oh no they sent more people to do more test on me. Why are they using a cookie cutter to take my skin? Wow the cookie cutter is all the way in my leg & they took a whole chunk of my skin out. I need to figure out how to escape this I need to get out. Let me text my friend to warn him I need his help. I want to listen to the waterfall so I can sleep.

^ none of this happened the way I thought. I wasn’t able to speak, or move for majority of it. I was on life support & I had no clue. I thought they didn’t give me the sponges because I was already in jail. My mom couldn’t hear me because I never actually spoke but I could see & hear certain things. The ‘cookie cutter’ was doctors taking a skin biopsy. At a certain point during this I became some what conscious? I told my mom to give me her phone & I texted my friend “turn off your phone or restart it”. He had no clue what I was talking about, or why it came from my mom’s number. I guess I wanted to warn him about something. The ‘waterfall’ was the bag of iv fluid dripping. I had no clue how close I was to death until I actually recovered.

I know this post is way longer than it needed to be, but please tell me if you’ve experienced things like this vs what actually happened (if you know/remember).

Hey all — long-time lurker, first post like this. Mods, if this isn't allowed, feel free to remove.

I'm a critical care clinician and I've spent the better part of the last year building an iOS app called Critical Care Vault. It started as a personal "I'm tired of opening five different references at the bedside" tool and grew into something a lot bigger than I planned. It's in the App Store now — free, no ads, no subscription, no tracking. None of that. I didn't build it as a business. I built it for myself and the people I work with.

Why I'm posting: I want feedback. I want to know what's wrong with it, what's missing, what doesn't match how you actually think at the bedside, what you'd never use, what you wish was there. The whole reason I'm sharing it is because the only way it actually serves clinicians is if clinicians tell me where it falls short.

What's in it right now:

 • Question Bank — 1,100+ clinical questions across critical care, advanced practice, and pharmacology. Newer questions include detailed rationales with citations. Spaced repetition built in.

• Hemodynamics trainer — 6 modes covering profile recognition, intervention selection, simulation, trending, and full reasoning chains

• EKG prep — anatomy, rhythm reference, 12-lead territory mapping, test-yourself mode

• PA waveform trainer — RA / RV / PA / PAOP, redrawn from real reference traces

• Drills — Meds (185 drugs across 32 sections), Labs, Fluids, ABG, Vasopressors, Ventilator

• Clinical tools — 13 calculators (MAP, CPP, CPO, APP, etc), 97 ICU protocol cards across every body system, antidote quick reference, drug reference, 60 clinical pearls

 

It's iOS only right now. Android is in Google Play closed testing — there's a live countdown on the website so you can track the launch ETA: criticalcarevault.com

App Store: https://apps.apple.com/us/app/critical-care-vault/id6763825778

If you have iOS and a few minutes, I'd genuinely appreciate you downloading it, kicking the tires, and either:

• DM'ing me what you think

• Hitting Settings → Report an Issue in-app (goes straight to my inbox)

• Or just replying here — I'll read every comment

 

I'm not asking for praise. I'm asking for the kind of "this is wrong, here's why" feedback you'd give a colleague. I want this to actually be useful, and the only way that happens is hearing from the people doing the work. Whatever lands — good, bad, or brutal — makes the next version better.

Thanks for reading.

I’m a critical care transport nurse and write a detailed narrative for every patient. Every narrative ends with a description of handoff at destination.

If the patient is obviously stable at time of handoff, I write that, but I’m always trying to improve my documentation. Is deciding “good” “fair” “poor” a vibes based description, or does it describe something objective?

Also, sometimes patients are “stable” on ECMO and pressors —as in clinical picture not actively getting worse and they are stabilized — but they are obviously very critically ill.

I’m curious how others use these words in their notes, particularly others in transport, doctors and NP/PAs.

At my hospital (where I work & not that I own) there is a policy that nurses only flush chest tubes to the atrium (away from the patient) and not the catheter (which would make sense to ensure patency)

This was not the case at my training institute and nurses flushed chest tubes once a shift as standard care

Is this common practice? What do you guys do

The unit I work with used to utilise patient diaries (hand written) for trauma/long term patients.

I know there is a lot of research about the benefits in filling gaps in memory, reducing ICU PTSD etc.

I'd love to get them back (having moved overseas and back where they had them)

But it is becoming quite difficult to move forward with legal requirements, where to document (should it be via the emr/not paper) and finally how to return diaries to patients once they are well enough. We don't have an ICU follow up clinic for this final stage.

Would love to know how your unit does it. I feel like they are are so beneficial for patients (and staff!) and I'm sad we're using them at the moment.

I'm not in the US, but open to any opinions/advice

After 3 years in ICU, I’ve officially decided to transfer to CVICU because apparently I enjoy stress and learning experiences that humble me daily. 😂

That being said… the thought of CVICU makes me wanna shit myself lol. The hearts, the devices, the expectations… yall are built different.

For those who made the switch:

-What was the hardest adjustment?
-What should I study beforehand?
-Any tips for surviving orientation without crying in the supply room?
-What do you wish someone told you before starting?

I know I won’t know everything overnight, but I really want to succeed and become a strong CVICU nurse.

Hey all-

I’m gonna be real because I’m genuinely stuck.

I’ve been an ER nurse for 2.5 years in a high acuity and well known hospital system in NYC. The ED is busy (roughly 50–70 patients/day), and I’ve been trying to get into the ICU since last August. I’ve applied to more positions than I can count at this point, and I’m either getting rejected outright or not hearing back at all.

I’ve taken care of vented patients, titrated drips, handled codes, and I’m comfortable in high pressure situations. I know that the ICU is a different mindset, and that’s exactly why I want to transition into a different specialty. I want to think deeper and really understand what’s going on with my patients beyond the initial stabilization phase and assisting patients with more complicated needs (also just enjoyed working with patients and sad to see them leave the ER when they go upstairs to their units).

At this point, I feel like I’m missing something fundamental. Is it because I’m coming from ER and not step-down and/or ICU? Just the current job market being brutal in NYC? Or having no internal referrals?

I’m open to honest feedback.. even if it’s blunt. I’d rather know what I need to fix than keep applying into a void.

******Also, if anyone works in an ICU that’s open to training ER nurses or has advice on how to actually get a foot in the door (or is willing to connect and refer me), I’d seriously appreciate it. Feel free to DM me.

TIA!

Edit: for context on volume, our ED often has ~50-70 patients on the board at once with around 20-30 admits holding but the winter season will consistently have the 70s on the board and triage roughly 150–200 patients daily, so it’s pretty constant turnover.

Edit: Every unit I've applied to, I've also emailed their managers saying that I was interested in their unit (no responses unfortunately). I also reached out to talent acquisition on feedback to make my application better, but they just told me, "Oh we will contact you if they want to move forward with you," or no replies.

Did you do any specific fellowship post Pulm Crit? Did you learn on the job? Do you like the transition?

My understanding is the following:

1. Hepatic fibrosis -> increased resistance to blood flow -> blood backs up into portal vessels​
2. Increased shear stress on blood vessels in portal/splanchnic circulation -> NO production​
3. Vasodilation everywhere (but splanchnic > systemic because more exposed to NO)​
4. MAP maintained via compensatory vasoconstricting mechanisms which preferentially effect systemic vessels (less exposed to NO) -> renal hypoperfusion -> RAAS/ADH/sympathetic activation -> sodium & water retention & increased cardiac output with increased HR despite low SVR and MAP = "hyperdynamic" circulation

In the above model I can explain the production of ascites pretty easily. There’s increased pressure in the portal system and congestion of the liver and mesentery / intestines -> fluid leaks out of these due to an increased hydrostatic pressure gradient -> fluid collects in peritoneal space.

What I can’t explain very easily is peripheral oedema. Even though there’s increased total body water and sodium there is decreased SVR and MAP. Therefore I can’t explain this based on an increased hydrostatic pressure gradient forcing fluid out into the interstitium.

What about oncotic pressure you say? We all know cirrhotics produce less albumin and that albumin contributes to intravascular oncotic pressure preventing oedema… However, we also now know that that is bunk. See a whole heap of literature in the last 15 years starting with Levick and Mickel and Thomas Woodcock on the revised starling equation.

We know from studies on nephrotic syndrome (https://www.kidney-international.org/article/S0085-2538(15)55610-X/fulltext ) and malnutrition (https://pmc.ncbi.nlm.nih.gov/articles/PMC9014367/) that hypoalbuminaemia does NOT drive oedema or third spacing and that separate mechanisms are involved in these conditions. In patients with nephrotic syndrome and oedema for example the interstitial oncotic pressure actually drops in parallel to the intravascular oncotic pressure such that there’s no change in the gradient. Serum albumin often being low in oedematous states is correlation, not causation. 

What I’m left with is simply increased permeability. I think this might explain things. Cirrhotics have a baseline endotoxaemia + increased circulating NO which would plausibly increase fluid movement out into the interstitium by itself.

Does anyone know if there’s any literature that’s looked into this question or mechanism? I struggled to find anything with a quick search.

I’m reviewing my case logs partway through my first fellowship year at a fairly busy academic community program. I was surprised to see I’ve only performed 35 intubations so far. I’m comfortable with the workflow of the pre- and post-intubation, and I only use VL. I’ve needed attendings to rescue me like 3-4 times, mostly due to massive aspiration or difficult anatomy.

I guess going into fellowship, I had no expectations of what numbers to hit my first year, but I suppose I just thought I'd get 50 or so intubations. Our ICU time isn’t front-loaded—it’s distributed across all three years. We manage most ICU airways, and for code blues, it’s whoever arrives first between us and anesthesia, though we usually end up taking the airway.

We don’t currently have an anesthesia elective (it’s reportedly in development). I do feel I need more reps, particularly with difficult airways, though I recognize ICU experience offers a different kind of training compared to the controlled OR setting.

I’m trying to gauge whether this volume is typical, if I’m on track, or if I should be more proactive with program leadership about increasing intubation opportunities. I only have one more ICU week, my first year, and that is night float; the rest are pulmonary consults, sleep medicine, and clinics.

Thanks!

I know I am interested in critical care, however there are so many residency options that can lead down that path. IM, general surgery, anesthesia, and EM all can do a fellowship in CC. How are the paths different in terms of job responsibilities and type of icu u will work in? Which one is the better route if i know 100% I want to do critical care?

Hi all,

I’m a HSCP, specifically a psychologist, and I do not usually work in environments with a bare-below-the-elbows policy. I am due to commence a position in an ICU, where I will of course be adhering to all standard infection prevention and control guidance and associated dress code requirements, including hair tied up, no rings or watches, and wearing scrubs.

This is all completely fine, although somewhat unfamiliar for me. My only query relates to skin integrity around my fingers. I have excoriation tendencies, which are exacerbated by stimulant medication, and this can leave the skin around my nail beds raw, broken, and vulnerable. At home, I often tape my fingers both to protect the skin and to deter further picking. But of course this won’t be an option in an ICU setting.

I am aware of the broader interventions for excoriation and this is an ongoing work in progress, particularly given the stimulant-related component. In the meantime, while I am still working to get this fully under control, I wondered whether there are any additional measures I should be aware of, or any practical steps I could take, that would be compatible with infection prevention and control requirements in an ICU setting?

Many thanks - a skin-picking psychologist.

My hospital refuses to provide the intensive care unit with a video laryngoscope; the emergency department and the anesthesiology department have a total of about four or five. I want to buy one, but prices in my country are inflated, so I want to import it. Do you know of any ways or brands I can purchase one from?

Hi! Newly graduated AGACNP student here. I am now applying for jobs, looking mostly at crit care. For context, I have 5 years of neuro, cardiac, and medical ICU nursing experience under my belt, and am hoping to continue my career in the ICU.
APPs who started as new grads in the ICU (or didn’t but work in an ICU now) - do you feel like a fellowship is worth the time/effort/salary cut? I know the learning curve is steep, and I’d like to come out of the next year feeling well-rounded and confident. However, the program I’m considering pays ~$72,000 in a HCOL area, which comes out to about $6/hr less than what I currently make as an RN.
The hospital I work at now does not have APP fellows, but I’ve heard mixed opinions from my classmates who have worked with them. The program I applied to is well-established and is described as strong and supportive by those who run it, but I’d like to hear your perspectives as well!
Thanks in advance for the help 🫶🏼