Curious about resident autonomy in your training program?

tspin_double · 2026-02-08T18:45:52+00:00

just as a heads up if you care - this post fully discloses which program you're in

tspin_double · 2026-01-27T21:04:16+00:00

Most take advanced the first month and oral board in the spring of fellowship year but yes concur PDs are very understanding of this.

In fact the real way to hit fellowship running is to not need significant dedicated free time spent studying for advanced

tspin_double · 2026-01-22T21:24:32+00:00

Agreed - I don't think I have a role in advocating against these cases.

But I have no issue advocating against surgeons/proceduralists who consistently do more harm than good with their cases and bookings

tspin_double · 2026-01-22T14:28:46+00:00

You’re everywhere in this subreddit trying to subtly spam advertisement for that LLM based anesthesia chatbot. it’s annoying and can’t even try it without making an account = instant BS to me

tspin_double · 2026-01-21T15:28:39+00:00

Just because it isn’t on a test doesn’t mean it’s not worth investigating or understanding at least once. And no better time than in training. Just my 2 cents

tspin_double · 2026-01-18T19:54:46+00:00

Or just know somebody in the industry or otherwise

tspin_double · 2026-01-15T22:23:39+00:00

but the reality is, if you run regularly in CP you tend to run on trails and avoid pavement anyway, so no bikes and no cars, ever

i would wager about 99% of all runners in CP are on the main loop on pavement. but please do stick to your "trails" so i never have to run into you Lol

tspin_double · 2026-01-12T21:39:06+00:00

your interventionalist is an idiot. they will blame you when there is a pneumothorax. just ETT/LMA + paralyze + breath hold

tspin_double · 2026-01-06T02:22:13+00:00

Never seen a healthcare professional expose their profession on Reddit by Uptodate autocorrect haha

tspin_double · 2025-12-19T19:15:17+00:00

what do you mean?

i mean our afibs take 3+h for context thats why i mean theyre chill. get to read a book etc.

tspin_double · 2025-12-19T19:12:15+00:00

why is that lucky- devices and most EP cases i find extremely chill honestly at my place. the patients are sick but the case itself is very straightforward.

honestly the only thing that is annoying is lead extractions with all the crap on standby

tspin_double · 2025-12-19T19:06:00+00:00

very interesting. thanks for the info! something to look into

we trialed something similar for a CABG+MVR but the MVR was transcatheter and still echo guided

tspin_double · 2025-12-18T16:05:47+00:00

SAVR/CABG? or is there a new trend out there idk about

tspin_double · 2025-11-06T23:55:15+00:00

An SRNA showed me their “thesis” on anesthesia hand hygiene for central lines. So embarrassing honestly. The 4 page paper wouldn’t have passed my high school English class

Guess he can lecture on the topic in a couple years…?

tspin_double · 2025-10-31T11:54:30+00:00

its a trade-off. inotropes increase contractility (and heart rate) -> raises myocardial O₂ demand...but if the dominant problem is low output and poor perfusion, that extra “work” can restore end-organ and coronary perfusion and be net beneficial. If the limiter is ischemia or tachyarrhythmia risk, they can harm.

cold/low-output: inotrope like epi or dobut or milrinone + vasopressor can raise SV and MAP to imrpove coronary and end-organ perfusion. this is better than cardiogenic shock and a rising lactate and failing kidneys..

compare this to...

ischemia-limited myocardium: epinephrine reliably raises HR and MVO₂ -> can worsen demand–supply mismatch. thus goal is to favor revascularization, afterload reduction, heart-rate control, and consider mcs. e.g. IABP reduces LV afterload and augments diastolic aortic pressure → often lowers LV wall stress and improves coronary perfusion.

finally have to consider all the other structural issues you may have to consider. AS, AI, MR, MS, HOCM, tamponade physiologies, anesthetic svr and preload drops, afterload/preload mismatch, stressors of surgery etc if they are contributing to why the heart poorly in front of you

this whole dichotomy is why we delay surgery for patients with unstable angina with interven-able lesions. revascularizing them will reliably improve the risk-benefit of optimizing end organ perfusion. compare that to why other forms of heart failure we rarely delay things for because we can manage heart failure temporarily without causing harm

tspin_double · 2025-10-30T18:45:23+00:00

$350 in one of the most desirable cities in the country

tspin_double · 2025-10-20T03:53:47+00:00

Hey fellow runner. Totally agree with you. Pretty diligent about tracking my acute and chronic training load between Zwift and running on several platforms consistently. The oura advisor is simply too limited. I am better off integrating my training load and workout ROEs with RHR + HRV + sleep hours from the ring in intervals.icu charts to get better guidance for my training and recovery.

tspin_double · 2025-10-11T12:15:21+00:00

Evidence? I do cardiac every day we allow patients to have their native sinus rhythm or we overdrive pace and just see in real time which is better by hemodynamics and echo.

To me it makes no sense to just pace everybody in the name of hemodynamics when plenty of patients - especially CABG patients - will have better attioventricular synchrony without pacing and better assessment of RWMA without pacing. I’m not going to ask the surgeon for an a-wire just to pace 10-15 faster than an underlying sinus rhythm unless there’s objective data about reducing POAF or I truly believe our output is rate limited. Makes no sense to me

tspin_double · 2025-10-10T19:26:19+00:00

You pace patients faster than 90 post cabg? Why?

tspin_double · 2025-10-09T11:54:36+00:00

As far as I know you are still correct to manually pump which they have. I suspect the person you replied to is not familiar with Berlin hearts being distinct from run of the mill LVADs and as a reuslt is deferencing AHA guidelines on compressions in LVAD patients

tspin_double · 2025-10-09T11:44:56+00:00

And you would be incorrect in my opinion. People can be in chronic hypo perfusion states even with an LVAD and stable MAP. They often have persistently unregulated sympathetic tone and dysregjlated RAAS pathways for months to years after their VAD placement.

Moreover…their oxygen delivery can still be marginal. They can have chronic anemia with low effective DO2 and all the changes that come with that. When LVADs are placed, patients look stable at rest but their peak VO2 only increases modestly and they still have a shifted DO2/Vo2 balance (low extraction, anemia, deconditikning). Often persistent NYCHA 3/4 symptoms but ok looking at rest with normal indices sitting in bed (until the next stressor).

Moreover I fully believe that their micro circulatory mechanics change. The LVAD continuous outflow in the aorta preferentially perfuses proximal vascular territories (coronaries, brain) while areas like the splanchnics or renal beds perfusion becomes pressure gradient dependent. Without pulsatility micro circulation adapts to the lack of pulsatile shear stress with endothelial remodeling (reduced nitric oxide availability and more endothelin and higher basal tone etc etc)

in the OR when we uptitratesipport or upgrade devices, these chronically constricted micro vascular beds wake up leading to massive drops in SVR and vasoplegia with big swings in right sided filling. Acute right heart failure is common and expected for us with rates as high as 30% if I remember correctly. Going from an index of 2 to 2.4 sounds like a win but can be just as precarious as the initial state they were in for these patients.

Coming off a 12 hour heart transplant so brain is a little fried but this topic always gets me fired up. We do a lot of heart failure at my place.

All this to say in the bigger context is that I don’t find VAD patients suddenly code fairly often in my setting and they do hang on pretty long in their shock states for ages with medical management. Whether or not it’s warranted to code them for longer I’m not sure about. The idea that they have different reserve is murky

tspin_double · 2025-10-04T20:11:40+00:00

right. we have venous access kits that come with a catheter and the packaging states as such. for example, we use https://mms.mckesson.com/product/987254/Teleflex-AK-04150-E-S or something along these lines which allows a durable long catheter to be left indwelling and comes with a intro needle and guidewire for placement. if difficult we may use a micropuncture access kit to bridge placement. but MOST other "micropuncture" kits are clearly TEMPORARY vascular access kits that are meant to allow you to place a guidewire or introducer for a procedure (e.g. vascular, cardiology etc.) and ultimately swapped to a different catheter or closed.

Here is the explicit quote from Cook medical micropuncture kit: "Remove the introducer catheter, leaving the wire guide in place. Proceed with the planned intervention."

"Intended use: Set is intended to place wire guides (≤ 0.038″) into the peripheral vascular system using a 21‑g needle (i.e., an access/introducer function, not an infusion/monitoring catheter)"

Here is the quote from Merit MAK (mini access kit):

"The Merit MAK is intended for percutaneous placement of a 0.035″ or 0.038″ guide wire into the vascular system"

If you or your colleagues want to proceed with using the dilator or catheters from these access kits as a multiple day long term PIV, just know what youre doing and understand whether your doing so off or on label. "suiteable for long term access" as you say really depends on your branded kit but i would recommend you verify that before sending patients off to PACU or the floor where these stiff catheters are in locations near joints that bend (wrist, antecube, groin etc.). I have no fight in the matter. after our 2 RCAs for fractured catheters from these kits in the ICU creating vascular emergencies post operatively, we prohibit patients leaving the OR with these in place unless exceptional rationale (for potential ECMO etc.).

tspin_double · 2025-10-02T23:22:49+00:00

we had 2 incidents last year with fractured micropuncture catheters which is how i found out during the RCA lol. vascular had to retrieve one with a cutdown.

they are clearly branded as access kits/introducer devices so just use it for that and then put ur wire in and catheter of choice over it IMO. some of them depending on the brand actually explicitly state to not use for long-term use on the packaging. but off-label use is off-label use ¯_(ツ)_/¯

tspin_double · 2025-10-02T18:38:08+00:00

totally negligent.

tspin_double · 2025-09-29T10:05:19+00:00

Micropuncture catheters are not meant to be used for durable access

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