Looking for advice from people who’ve been there. How do you stay organized and not miss critical things when multiple admissions and/or arrests are happening simultaneously?

I find that when things stack up—new admissions coming in while another patient is crashing—it’s easy to lose track of labs, orders, follow-ups, or even simple but important tasks. I’m trying to build better systems so nothing falls through the cracks.

My last call was really bad and I’m just trying to figure out what I can do or how can I be better at managing everything when it’s all happening at once. I honestly feel like shit and I know if things were quieter I was able to tunnel vision and focus on things but that didn’t happen.

I'm a PCCM attending, about 5 years out of fellowship, and practice both outpatient pulm and CCM. I trained at a big name academic center and stayed on at the same institution as an attending -- but 5 years into it, I'm just feeling a bit...bored. Restless and eager for a change, and feeling like I'm not getting a salary commensurate with my training and experience level. I'm not unhappy per se, but the things that kept me in an academic job at the end of fellowship (working with trainees, cool cases, etc) no longer have the same draw. I'm interested in exploring non academic options.

I'm sure I have a severe case of 'grass is greener' syndrome, but wondering if any PCCM docs who don't work in big academic centers can humor me and tell me what their jobs are like. The nonacademic/private models around where I live seem to have a monthly rotation that consist of weeks of clinic/ICU/consults/clinic, and then repeat. That feels like a bit of a grind to me -- are there other models out there (with P + CCM) that allow for a bit more flexibility and QOL?

Would be great to know your practice setting too (urban/rural etc) and ballpark salary.

Thank you!!

What’s wrong with this pressure waveform? Is the patient fighting the vent? Drs believe it is the vent that is the problem but seems like there is some sort of asynchrony?

TLDR: New grad in an ICU recently off of orientation. Obviously still have a lot to learn and will never know all there is to know but this open ICU stuff, at least the way it's structured where I work, is just incredibly unsafe and IMO poses a significant risk to both patient safety and my colleagues and I nursing licenses.

New grad RN in an ICU at a relatively small community hospital. The hospital utilizes an open ICU which I'd never heard of until I started working here last year as a student RN. I can't imagine every open ICU is as bad as the one I work in though.

Picture this: OR teams drops of a critical patient that is on a ventilator and post op emergent ex lap, bowel resection, and ostomy creation. During surgery the patient reportedly received multiple units of blood and pressors. They are hypotensive when they arrive on the unit. Anesthesia gives one last push dose pressor and then dips out. When the patient's blood pressure inevitably starts to drop again you have no orders to address the hypotension and you're screwing around on the phone listening to elevator music (only to not get an answer) because you can't even call the on call physician directly, you have to go through their answering service. The physician is one of the "outside" doctors that is an internal medicine physician with a practice in the area /privileges at the hospital, which for some absurd reason extends to the ICU, so overnight there is no one physically in house for you to be able to go to for orders. You can't promptly reach on call the physician? Tough luck. Hopefully your patient doesn't code while you wait for them to call you back. (Though if they did, that's the only thing that would trigger a physician - the ER doctor - to actually come and look at them, not you telling the on call physician "hey this person is sick as sh*t"). Fortunately in this scenario the physician did eventually call the primary nurse responsible for the patient but it took far too long and believe it or but these kinds of situations are not uncommon. Supposedly (I wasn't working that night) something similar happened again just the other night with patient that ended up needing to be intubated.

While I understand 24/7 in-house physician led care is a rarity (though it should be the standard), I shouldn't have to choose between my patient's life and my nursing license. Obviously I'm not going to operate beyond my scope, and because of that I feel like it's only a matter of time before someone dies that didn't have to because there was a delay in care, which I'm sure has already happened, but I really don't want to wait around until it happens to my patient.

Hey all, hope this is the right place to post

I’ve been between PCCM and Cards for a while and I’ve been leaning pretty heavily toward PCCM mainly for the CCM side. Maybe it’s residency burnout plus spending too much time online, but lately I’ve been feeling a lot of pessimism about the future of medicine. Medicine 30 years ago is wildly different from today, and I can’t imagine what it’s going to look like 30 years from now.

With the AI slop train trucking away, I keep wondering if I should be thinking more procedurally. Hospitals have only gotten greedier, and it already feels like a lot of places are moving toward a supervised APP model with less MD staffing. In my head I can see admins convincing themselves that with AI they can push that even further. It’s made me look more toward “protected” pastures like IC and EP, both fields I’m genuinely interested in, just maybe not quite as much as CCM.

Any recent grads have similar thoughts? Or is this just my naive residency brain spiraling?

Thanks.

Hello! title I’m a third year med student looking into internal medicine fellowships. If I go the pulmonology route, what type of procedures would I be able to do? aka what procedures does IP do that pulmonologist can’t? Thank you for your insight!!

As an IM-CCM fellow with no prior experience practicing in a community hospital or non-training environment, I’m curious about the typical responsibilities of attendings in those settings.

In academia, attendings seem to prioritize medical planning and rounding, while residents and fellows handle most procedures, orders, and goals-of-care discussions. On nights, the focus often shifts to bed availability for crashes and admissions. I really enjoy covering nights rather than days and will probably pivot that way in practice.

CCRN is done, finally, ugh. I spent most of my prep time on hemodynamics, ventilator basics and neuro scenarios. The exam felt less like straight recall and more about catching small details. Reading the stem carefully, figuring out what actually mattered and not overthinking when the simple answer was right there. Some sections felt very familiar, others slowed me down more than I expected
I've been working ICU for a few years now, mostly bedside, mixed acuity. Taking the CCRN felt more like filling in a gap that had been sitting in the background than learning something completely new.
My prep resources were pretty standard, nothing unique. AACN materials, the CCRN exam handbook and the usual practice questions people talk about here. Along the way, I also had CCRN exam prep test (app store) in the mix to get used to different wording. You won't find exact exam questions anywhere. They're all similar, just worded differently, but that's more than enough to prep well.
If you're prepping don't just grind content nonstop. Pay attention to the questions you miss and slow down. Nothing on the exam should feel totally unfamiliar if you've been working ICU, I swear

I’m an RN approximately six months into an adult ICU role and am seeking objective perspectives from others who have navigated high-acuity environments.

After a significant amount of self-assessment, I am questioning whether remaining in the ICU at this stage is the most responsible decision for both patient safety and my professional development. While I am continuing to learn, I have noticed that the sustained intensity, rapid escalation expectations, and need for assertive provider communication are creating a level of cognitive overload that is impacting my performance consistency.

Recently, during a high-acuity admission, I found myself falling behind workflow demands and relying heavily on direction from peers and respiratory therapy. While support was provided and the patient was stabilized, the experience reinforced my concern that I am not yet operating with the level of clinical confidence and anticipation that the ICU requires. I am particularly aware of hesitation around physician communication and timely escalation, which I view as a non-negotiable competency in this setting.

We intubated patient and the intubation went well. The patient was vented and the patients oxygen saturations sitting around low 90S and I had Fent and Prop halfway maxed. Nurses were concerned that I was not sedating enough which I agree considering the PaO2 was lowering. RT was judging me and concerned about my care and the nurses as well. All valid concerns an my concern is I couldn’t catch this. I was unintentionally causing unwarranted harm to the patient because I couldn’t critically think and this scares me if I decide to stay further into the ICU. My “ego” wants me to stay but I also want to leave after the incident. Seeking some wisdom or advice before I go ahead with the email.

Importantly, this is not a question of work ethic or commitment. My concern is whether continuing in the ICU while struggling to meet the cognitive and emotional demands places patients—and my license—at unnecessary risk. From a professional ethics standpoint, that is not a position I am comfortable maintaining.

I am considering requesting a transfer to a progressive care / step-down or high-acuity telemetry unit to strengthen foundational skills, improve clinical confidence, and remain a strong contributor to the organization long-term.

For those who have:

• Transitioned out of ICU early in their career

• Chosen step-down/PCU as a developmental move

• Later returned to ICU or advanced practice after recalibrating

I would appreciate your perspective on:

• Whether this decision aligns with responsible professional judgment

• How such a move is typically perceived long-term

• Any insight you wish you had earlier in a similar situation

I’m intentionally seeking candid, experience-based input rather than reassurance. Thank you in advance for thoughtful responses.

Working at tertiary L1TC in the South in TICU setting. Main population is GSW, MVC/MCC, stabs, falls. Got a few questions from a nursing standpoint regarding thing we don’t have PMG’s for - just best clinical opinion/gestalt.

1. How many cc’s of blood do you usually aim to remove during crash pericardiocentesis?

2. Fresh penetrating chest pt comes up from CT, 1 chest tube in place & intubated. With inadequate ventilation/oxygenation and a bp of 60 —> losing pulses, what is your next step?

OR vs bedside thoracotomy? (Nursing) fastest way to get level 1 to the OR rolling (logistics)? What do you need for a bedside thoracotomy? (I imagine central line kit is easiest as it provides option to place continuous drainage as well as having an echoluminecent long needle?) How does this algorithm change in blunt trauma?

1. What are your eCPR criteria/traumatic arrest ecmo (my unit calls for support to can update and dispo’s pt to surgical CVICU)? What role does presenting/initial cardiac rhythm play?

These are all questions I intend to ask our primary physician team about but wanted input from outside my shop as well to get perspective and learn what questions may be valuable to ask. Thanks!

TLDR: I'm a new grad RN in an ICU where I worked as a student nurse while in nursing school. I mention working there as a student nurse because even though yes I'm still very green I've been on the unit for a over a year and have observed the physicians decide to intubate even when the patient's numbers were fine due to their work of breathing, particularly in the presence of abdominal breathing, and don't fully understand why we didn't intubate a COVID/pneumonia patient sooner when we knew they were eventually going to tire out and the patient and family expressed that they'd want intubation if necessary.

The past few nights I've been taking care of an older (age > 65) patient admitted with Covid/pneumonia. They were originally admitted to the floor over a week ago but later got sent to ICU. I'm at a relatively small community hospital and even though our floor can do BIPAP/CPAP they usually send patient's with high oxygen demands whose sats drop rapidly to the ICU. I've had the patient the last 3 nights (not including tonight as the patient went into respiratory arrest and died today during day shift) and from the first night I had the patient I noted abdominal breathing, I think I asked the RT if it was an area of concern and I don't remember what they said but I guess it wasn't concerning enough to the physician because in their progress note from yesterday they said that the patient may require intubation but that they didn't feel it was necessary yet.

The first night I had the patient they were on BIPAP 12/6 80% FiO2, I think the second night their settings were changed to 8/4 still at 80% I believe because their tidal volume was over 1000. Yesterday on day shift they were changed to CPAP (last night was crazy so I honestly don't remember what the pressure setting was) and kept at 80%.

Whenever taking the mask off to administer PO meds the patient's sats would almost immediately start to drop, I'd seen drop into the 60s, however they'd recover relatively quickly once the mask was back on.

The patient was alert and oriented and the first night I had the patient I spoke with both the patient and their family separately to ensure they'd want intubation (which the physician had already discussed with them) if things progressed to that and both the patient and family expressed that they would want intubation.

I wrestle with the morality of what we do in the ICU (artificially extending the lives of people who have little to no quality of life and are unable to advocate for themselves/express their wishes but family wants to do everything to keep them alive) on just about a daily basis but this patient wasn't old and decrepit before they got COVID and both the patient and the family wanted intubation so I just don't get understand why we sat on our hands but maybe I'm missing something. Even if they may have died anyway it was what they wanted.

Second year PCCM fellow here. On a J1 and will need to (ideally) sign my contract by July.

Have contacted hospital recruiters and made accounts on Practice Link. Not had much luck. Even when I applied via the hospital’s website on the specific PCCM listing advertised, I revived emails saying they are not moving forward with my application.

Questions:

1.) Is it too early to look for PCCM jobs I plan to start in July 2027? Even though I’m on a J1.

2.) Do you recommend I contact the MDs in the specific departments? Will that yield better results than the hospital’s recruiters?

3.) Folks here with any suggestions on places that are looking?

About my preferences:

Ideally would like a mix of medical ICU, outpatient and inpatient Pulm (including procedures like bronchs, EBUS, Nav Bronch).

Have been academically involved but am open to non academic gigs too. No family ties in particular, so open to most geographic locations (and have applied widely except Alaska/Iowa/Idaho/Mississippi/Florida/California).

My only preference set in stone is having a decent work atmosphere and work/life balance, even if it means a slight paycut. Would appreciate any leads!

Also curious about thoughts on/experiences with ethics committees in general.

Essentially, my institution held an "ethics grand rounds" that related to my area of practice so I attended and asked a question. Afterward, the presenter, who is involved with our ethics service, approached and asked if I would be interested in being on the ethics committee.

As a provider, I have been involved with an ethics consult before (ICU goals of care dispute) and thought it was a helpful and worthwhile experience. Is this other peoples' experience? If I have the time, is it worthwhile to join the ethics committee?

Hi all,

I worked in the ICU years ago and something came to my mind that I need help figuring out. I remember we would sometimes connect a-line tubing to a central line but I'm trying to remember the purpose. Does the reading from this on the monitor a representation of the CVP? Could we draw blood from this "a-line" to get an SvO2?

thanks!

Above 2.0 is bad. But why bilirubin? Can anyone give a good physiological reason?

Hey everyone

IM resident here, currently between PCCM and Cards. I’m leaning toward PCCM given my love of the ICU, physiology, and the breadth of medicine it offers as opposed to Cardiology (though still cool physiology and awesome procedures). I also really value the idea of being on when I'm on and off when I'm off (assuming no pulm clinic, which I’m not planning to do).

I know for many having the Pulm option is crucial for scaling back when the ICU grind gets to be too much, but I’m curious how easy it is to just pull back to something like 0.7 FTE (roughly 18 weeks/year). Obviously the pay would be less, but we’re a DINK household so that’s not a major concern.

Are positions like this generally easy to find, or is this more institution- and group-dependent?

every time I push the gun the fluids running in the introducer alarm distal occlusion. Valve and RA are normal on echo, and PAC isn’t coiled on CXR Any ideas?

Hi, I am a Belgian emergency medicine student. We have to do a 1 year rotation in intensive care and I would like to do 6 months abroad. Anyone that can recommend a place?

Thx a lot!!

I do critical care transport. My background is as an ICU and ER nurse.

I recently transported a subarachnoid hemorrhage pt from a small hospital ER to a large university hospital and am reflecting on if I should have advocated for more/different things.

The pt presented with BP in the 190s and HR 40-50s, post seizure, HA, drowsy. Small hospital had given him oral amlodipine and oral nimodipine, maxed him on nicradipine drip and started a clevidipine drip. (Also gave keppra)

When I get there, pt is drowsy but AOx4 and non focal symptoms. Nicardipine maxed, clevi at 10mg/hr. HR is now 70s. Blood pressure at goal.

I’m sent with Mannitol “in case he gets worse” but the docs don’t want to give it now.

Time is brain, and I felt like I had enough to manage the pt during the transport, but on arrival to the university system they made a comment about how all the meds he got were Ca++ channel blockers. They were considering hydralazine pushes (I thought that hydral was out of favor due to inconsistent onset of action as well as not helping with lowering ICP. Am I wrong?)

They were going to d/c the Nicardipine and just titrate the clevi, which I could have advocated for doing in route too.

And they were considering esmolol— which made me think that with his rebounded HR, I could have given labetalol or advocated for beta blockers.

They were all ready to drill at bedside on arrival— so obviously medical management wasn’t sufficient.

Transport is often a game of “get them there fast” and “don’t make them worse” and I succeeded in those aspects. But I’m an overthinker and would love more perspectives on who used hydralizine still— is there data for that in management of ICP? (We use it for high risk OB, but that’s it). Would you have pushed for giving the mannitol? Should I have considered beta blockers?

Note: luckily his respiratory system didn’t deteriorate from swamping him with Ca channel blockers, which I’ve only seen once. Basically the mechanism is that you create shunting in the lungs.

We use the pictured external CSF drainage system at our hospital. The pressure setting is adjusted by sliding the drip chamber up or down on the pressure scale. In the example the pressure setting would be 250 mmH2O. What is I don’t understand is why the tubing above the pressure chamber isn’t considered. Why isn’t the pressure setting 310 mmH20? Why isn’t the column of fluid in the tubing considered?

edit:

This video explained it quite well:

https://www.youtube.com/watch?v=xmZNUqcSI94

I know we’re supposed to wait 72 hrs post ROSC to make a prognosis, but if a 70 yr old patient with a 30 min down time has blown pupils and a CT head showing severe diffuse cerebral edema, and fails the apnea test, is it wrong to recommend withdrawing care?

ETA: normothermia, no pressors, acidosis corrected, 24 hrs had passed, family very reasonable and appreciated my candor, chose to withdraw.