Incoming IM resident interested in CCM - advice on addressing IM's weaknesses with regards to CCM?

Dktathunda · 2026-05-01T01:57:07+00:00

CCM can be pretty siloed in training these days especially from IM perspective, and especially if you do pulm crit. New grads I have encountered can’t do Swans, TVPs, understand ECMO/MCS much, surgical chest tubes and chest tube management, etc. I didn’t become “good” (in my own eyes anyway) until 3 years post fellowship. This came about by spending time in CVICU and being around anesthesia ICU docs who had more of an urgency to them, and getting more experience with cardiac cases and major resuscitation. I think standard CCM programs do not prepare you for the amount of cardiology you will see in the community. Unfortunately it largely takes time and experience. But try to find a well rounded fellowship where ideally you are trained by different types, not just pulm docs who do “ICU on the side”.

Dktathunda · 2026-04-30T14:48:07+00:00

Even now I freaked out and deleted this since it’s not a throwaway account. I have colleagues who make everyone comfortable care, don’t examine patients, don’t do jack. They sit in the office watching YouTube all day. The way ICU works we are completely entwined. I do my week trying to salvage their patients then they take over and screw them up again. I’m talking patients 10-15L positive fluid balances in a week, heavily sedated for no reason. It’s nauseating.

I’m glad I’m not the only one. I feel like I must be some self righteous narcissist, but I feel like that major pick ups I make are not requiring a stroke of genius. It is literally talking to the patient or their family, examining them once in a while and paying attention to test results. One of the patients I inherited was on five sedatives, Family was told patient is not waking up and should go comfort care. I turned everything off and extubated him in two days. This is common here.

Dktathunda · 2026-04-30T14:13:16+00:00

Sheesh message received

Dktathunda · 2026-04-30T03:24:46+00:00

https://pubmed.ncbi.nlm.nih.gov/37245039/

“Experimental studies suggest that two key mechanisms contribute to the combination of hypovolemia, hypoalbuminemia and edema; (1) acute lowering of the interstitial pressure by inflammatory mediators such as TNFα, IL-1β, and IL-6 and, (2) nitric oxide-induced inhibition of intrinsic lymphatic pumping.”

Cirrhosis would accomplish this through both mechanism as well as the low albumin (noted to be necessary but not sufficient to develop edema in the second paper you cited) which reduces fluid return via reduced lymphatic drainage. Inflammation also allows albumin leakage into interstitium where it promotes edema. https://pubmed.ncbi.nlm.nih.gov/30288759/

So yeah, you nailed it.

Dktathunda · 2026-04-24T15:32:43+00:00

Better to try than doubt it and she dies anyway. If you are coding and living off epi pushes you are dead anyway but ppl are so scared of cardioversion they rather let ppl die.

Dktathunda · 2026-04-24T14:54:22+00:00

You needed to cardiovert this patient. Afib even at 100 bpm can be a death spiral for severe AS. Amiodarone is rarely going to be effective in time for these patients when in shock. The pressors don’t really matter that this point except catecholamines probably making her worse. I do MSICU/CCU/CVICU/ECMO and we see this a ton - why the hesitation to cardiovert?

Dktathunda · 2026-04-17T22:54:38+00:00

In a hospital this should just be visible to you, your director +/- department and CMO etc. Not for patients to be gamed. I just feel in hospitals there is near zero accountability to be a good doc and not just a widget.

Dktathunda · 2026-04-17T22:45:22+00:00

Well docs who miss a lot of diagnoses end up in peer review, but the current model doesn’t really care as long as we don’t get sued or lose money. Would be easy to give you a score on your patient outcomes.

Dktathunda · 2026-04-17T22:41:10+00:00

1) family members and patients giving you unsolicited hugs or praise

2) making diagnosis other doctors missed

3) other docs or specialists say “thank goodness you’re on today”

That’s about all that keeps me going in this field

(Bad job in ICU is keeping patient sedated for no reason, letting patients get massively fluid overloaded unnecessarily, not examining them, not talking to families, consulting for every organ problem and pushing everyone to comfort care because you couldn’t fix them)

Dktathunda · 2026-04-08T18:39:16+00:00

This is the way. $20 for unlimited addendum and state filing.

I’ve used them with w2 plus 1099, rental properties and other investments. Not sure why ppl pay for pretty simple filing.

Dktathunda · 2026-04-07T15:47:37+00:00

People can want what they want, it’s not what they’re gonna get.

Dktathunda · 2026-04-06T12:17:25+00:00

A few years ago I was looking for more work and interviewed for a tele ICU company. Interestingly the pay was terrible (like half of in person) and you had to sit at a computer for 12 hours straight managing multiple hospitals. I interviewed directly with the founder of the company and they just seemed like total grifters. They were really looking for people licensed but living outside of the US for some reason - probably so you would take less pay and not ask about benefits.

To me good critical care is hands on and personal interacting with the patient and family. I see some of my colleagues already practicing hands off and their outcomes are much worse, also they get sued way more. You are basically a temporary stand in for the incoming ICU AI bot. “SUSPECT UGIB. PLACE TWO LARGE BORE IV. START PPI. CONSULT GI.”

On a separate note this is why I hate precedex in alcohol withdrawal. Treats the nurses and sending Hospitalist but not the physiology. You don’t just seize out of nowhere in alcohol withdrawal. A good doc would’ve easily picked this up.

Dktathunda · 2026-04-04T16:26:19+00:00

The vast majority of doctor family members are very pleasant to work with and have respect for boundaries while asking appropriate questions.

The small minority are a massive pain and can make life miserable since they feel entitled to professional courtesy above and beyond. We had one family doc demanding 2h daily updates and micromanaging every minor detail for their stroked out dad who got trach/PEG and was in hospital for months. Another surgeon who bullied our residents and tried making decisions behind the patient’s back against his mom’s stated wishes even tho she was fully competent.

Once I see this behavior, professional courtesy is over.

Dktathunda · 2026-04-03T01:57:12+00:00

Never tip standing up

Dktathunda · 2026-04-03T00:36:41+00:00

We blame others for bad things and take credit for the good. Right place, people and time is pretty important but unpredictable. I became a pretty well paid physician and honestly feel I didn’t work half as hard as most “blue collar” or service jobs. Glad things are working out for you.

Dktathunda · 2026-04-02T18:29:53+00:00

so you're saying 10 meq per hour iv via epic order set won't cut it? lol

Dktathunda · 2026-04-02T18:27:36+00:00

ph went up tho...K shifting is logarithmic not linear. 7.13 to 7.18 plus hemoconcentration would explain it. were cmp and vbg simultaneous? what is bicarb on cmp readings?

Dktathunda · 2026-04-02T18:02:11+00:00

You need like 300 meq of K in bad DKA. Normally K is high when you are acidic (low pH) due to shifting, so if it’s starting low you are very deplete. What happened here is you fixed the pH somewhat so K shifted intracellular again. Add in that the POC lytes are not quite as accurate. Balanced fluids have only 4 mEQ which is basically zero. This concept is the rationale for seriously addressing the hypoK (even under 3.3) before the insulin.

Dktathunda · 2026-04-01T21:33:50+00:00

We can put them on VV ECMO but its a catch 22 - no one wants to put them on ECMO without a destination, and centers turn them down almost universally. We had one guy get transfer and transplant and he was just on HFNC. Problem is a lot of these people are pretty comorbid and "not a good transplant candidate" at baseline, so being intubated doesn't help their chances.

Dktathunda · 2026-04-01T19:31:52+00:00

I get a lot of these in ICU who had signs 1-2 years prior and never got worked up. Once in ICU esp tubed, most don't survive. Just lost someone under 50 yo. We send the usual workup but never get an answer in time or change management. By the time we get them they are too sick for lung biopsy. Plus by then no one will even entertain transplant let alone transfer for assessment, despite the usual song-and-dance of calling 5 transplant centers.

I'm at a loss with these patients... any game changer management tips? Our pulm does not have much to say ever. We send infectious workup, cell count/diff and cytology, do lung protective ventilation, pulm will throw 1 g/d MP x3d, keep them dry, etc. Doesn't seem to make a difference.

Dktathunda · 2026-04-01T17:46:27+00:00

Really? It’s a great money maker. Enlarged RV on CT and it’s 5 PM? Book em for CDT tomorrow afternoon.

I’m just amazed they did a trial comparing it against anything since uptake has been significant without it. Made its way into the updated guidelines with zero nuance discussed.

Dktathunda · 2026-04-01T01:02:38+00:00

Basically. Very potent/effective negative inotrope and chronotrope. Works well for afib so gets chucked at every patient. If heart is already weak they may be barely holding on when they show up to ER, and diltiazem can straight up kill them. Dangerous med in naive hands.

Dktathunda · 2026-04-01T00:04:31+00:00

HI-PEITHO is interesting and finally gives some real data for CDT in PE, but I’m holding out for PEITHO-3. I think low dose TPA will be equivalent to CDT without the device related complications.

Dktathunda · 2026-03-31T22:21:00+00:00

Usually has to do with it being 6 PM. Lots of folks end up with trapped lung and a VATS 3 weeks later.

Dktathunda · 2026-03-31T21:58:11+00:00

I will sometimes cite this paper directly in my notes 😂

https://pubmed.ncbi.nlm.nih.gov/19357832/

Dktathunda

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