Author: Bryan Boling

I'm a critical care nurse practitioner and co-director of the Critical Care APP Fellowship Program at the University of Kentucky. I split my clinical time between the Neurocritical Care Service, the Surgical Critical Care Service, and the ECMO Service. I'm also an Adjunct Faculty Member in the Acute Care Nurse Practitioner Program at Georgetown University. I have a passion for education and #FOAM.

Keeping Up with the “Literature,” Part 3

In the previous 2 posts, we’ve talked about how to keep up with the critical care literature. Eddy Joe Gutierrez shared his process and I started to make my case for using social media/podcasts/blog etc. as a tool for this process. I think the fact that you’re reading a blog (and likely following this blog on Twitter as well) means that you’re on board with the idea of this type of media as education and hopefully you can see how it’s helpful in keeping up with the newest info and research.

In this post, I’m going to give you some practical tips for managing the non-traditional literature, because although it can be very helpful, there is so much out there that it can easily become overwhelming as well! The good news is, there is already some baked-in benefits that we can take advantage of to help organize and manage things.

Social Media

Let’s start here. Twitter and Instagram are my two major sources of social media, at least for this sort of thing (I have a personal Facebook page but I use it almost exclusively to stay connected with friends and family). The first thing to do in order to make use of Twitter for keeping up with the latest in critical care is to start following a diverse group of people and organizations. Most professional societies and journals have Twitter accounts. In addition, there are a lot of great podcasts and websites that provide critical care education and you may be using already who are also on Twitter. Finally, there are a number of great accounts out there who are just “regular” critical care providers who are passionate about this sort of thing and will share articles of interest. This is why I recommend following a variety of different people, in order to get a wide range of interests represented.

To make this easier, you can use the lists function of Twitter. You can use this to create curated lists of a specific topic. You give the list a name and then add Twitter accounts to that list. The list won’t necessarily be limited to that topic, it will include anything by the people you add to that list. But, it can help to organize things. Additionally, you can follow other users lists. So, if you see someone who tweets about a topic that you’re interested in, and they have a list of that topic, you can follow their list. Whenever you’re interested in reading about that particular topic, you can pull up the list (yours or someone else’s that you’re following).

I’m newer to Instagram, so I don’t have any great tips for organizing the stream there. If anyone knows, please let me know (best way is to post on Twitter @CritCareNotes). But, Instagram is quickly becoming one of my favorite sources due to the visual nature of the medium. Photos and videos are so helpful for learning and keeping up with the latest and greatest. People have told me that Tik Tok is becoming a great source of short videos as well, but I haven’t made the jump there just yet.

I’m going to break this up here. I’ll cover my approach to podcasts and blogs in the next post.

Keeping Up with the “Literature,” Part 2

Earlier I shared a post about how Eddy Joe Gutierrez stays on top of the critical care literature. I mentioned that I also use social media/podcasts/blogs/etc to help me stay on top of things and promised a little more later.

So, I put literature in quotes in the title, because a lot of people don’t consider this sort of thing to be “the literature.” And in the strictest sense of the word, it’s not. However, in 2022, we can learn a lot about the current state of critical care research and practice from these non-traditional sources (hence the entire raison d’etre of this blog). Many of the podcasts, blogs, etc out there cite sources for their information, it’s not just “expert opinion.” And, these tools make it easy to digest info in 2 main ways: crowdsourcing and enabling on-to-go learning.

Crowdsourcing, if you’re not familiar, is the concept of getting input from a variety of people in order to answer a question or deal with a problem. It’s the 21st century version of sharing the work. Social media is a great way to crowdsource your literature review. Because there are so many critical care professionals out there on Twitter, Instagram, etc., and they can all post about the latest literature that interests them. By following a wide variety of people, you can get posts about a wide variety of interests in easily digestible bites.

The other huge benefit to this is the on-the-go nature of this medium. I’m busy. I’m sure you are too. I don’t have a lot of time to sit down and read a journal. But, I do have time to listen to a podcast (more on that in a bit). I can also listen while doing other things. My favorites are to listen during my commute, while mowing my yard, and while walking my dog. I used to listen a lot at the gym as well, but find that I can’t focus as well, so I reserve those for podcasts about things I don’t have to concentrate on (typically topics I already know and just need some refreshing on). I also have time to scroll through Twitter or Instagram while I drink my coffee in the morning. These posts are short and I can bookmark anything interesting to look at later.

OK, this post is getting a bit longer that my usual, and I’ve got a lot more to add, so I’ll save the nuts and bolts of how I manage all of this for next time.

Keeping Up with the Literature

If you’re like me, your inbox is full of stuff that is crying for your attention. And you likely have a stack of journals in the corner of your office for “when I get some time to read.” There is a non-stop onslaught of information coming at us every day, and this is especially true in critical care. If you’re also like me, you probably have said, “I want to make sure that I’m giving the best possible care to my patients, but how can I stay on top of all the newest literature?”

In this great blog post and podcast episode, Eddy Joe Gutierrez shares with us how he stays on top of things and keeps up with the latest and greatest in critical care literature. I love a lot of his suggestions. Some I currently do (Critical Care Reviews is essential!) and some I’m thinking about implementing in my own life. One thing I have found super helpful in keeping up with things in social media/blogs/podcasts, hence, this site! I’ll be doing a separate post on how I manage all of that and use it to help me personally stay on top of things. Right now, check out Eddy Joe’s strategy to keep up with the literature.

Estimating Cardiac Output with POCUS

I always love learning new things to do with POCUS and learning new POCUS skills. Pulse wave Doppler is not a mode that I use often and it is on my list of things to practice with. I think there are a lot of really nice benefits of it in the management of critical illness and shock. Now, at first you may have looked at the title of this post and thought, “I know how to do this, EPSS or fractional shortening. But those don’t use PWD? What gives?” Well, E-point Septal Separation (EPSS) and fractional shortening don’t use pulse wave Doppler, they use simple M-Mode. But, they also don’t measure cardiac output, they measure left ventricular ejection fraction (LVEF), and those 2 aren’t the same.

Matt Siuba explains why we want to measure CO as opposed to being content with LVEF in this video from the Zentensivist YouTube Channel. He also explains everything you need to know about pulse wave Doppler (or at least everything you need to know right now) and how to use it to measure the CO. Don’t worry, there is nothing wrong with your ears, the audio is sped up to 1.25x in order to reduce the time of the video to 14 minutes (this is critical care, time is brain! and heart! and…you know, we’re busy!).

Lewis Lead

One of my pet peeves in the ICU is when we just randomly slap ECG electrodes on patients in “roughly” the right spot. The one I see done most often is the brown electrode (the precordial lead for the monitor). It’s often just slapped down wherever. In fact, I remember being taught the mnemonic devices “smoke over fire,” “snow on grass,” and “white on the right” when I was a new nurse to remember the limb leads. But the one that I was taught that is horribly incorrect is “brown is the sh*t in the middle.” Thus, it didn’t really matter where the brown electrode was placed.

But it does matter. There’s a lot of useful info that you can get if the leads are positioned correctly. And there are other ways to arrange all the leads on the monitor. Some of these will get you different information. One of these configurations is the Lewis Lead. Credited to Welsh cardiology Sir Thomas Lewis (it’s too bad I’m not Sir Bryan Boling…), this is a way of arranging the ECG electrodes to better detect atrial activity, such as amplifying the waves in atrial fibrillation.

Robert Buttner and Mike Cadogan over at Life in the Fast Lane have a great post describing the Lewis Lead, it’s history, it’s usefulness, and how to do it right. Check it out. And please, stop just putting the brown electrode wherever.

Being Ambidextrous

I want to highlight an episode of our podcast, Critical Care Scenarios, today. But, it’s an episode I had nothing to do with. My co-host, Brandon Oto, has started an occasional series called TIRBO (The Intermittent Rantings of Brandon Oto) where he just talks for a few minutes about a particular topic. In this episode, he discusses doing certain procedures with your non-dominant hand. I wanted to share this in case readers aren’t regular listeners to the podcast (why aren’t you??). Also, I thought I’d take a minute to add in some of my thoughts.

I teach a lot of procedures. I teach our APP Fellows. I teach procedures to our students at Georgetown University. I do central line workshops for all the new APPs/CRNAs in the Department of Anesthesiology at UK. And one thing I’m constantly harping on is positioning. Positioning the patient and positioning yourself. This is the number 1 cause of procedural troubles (I don’t have RCT data to back that up, but I stand by it).

Twisting and contorting yourself not only is a good way to hurt yourself, either acutely or over the long term, but it’s a great way to make a simple procedure really difficult. If you’re uncomfortable, you’ll subconsciously rush and take short cuts. Your body wants to make the discomfort stop and the best way to do that is to stop doing what’s causing the discomfort (i.e. the poor position). But, most critical care providers are stubborn and so we won’t quit until we get it. So, we rush. Which in the long run actually prolongs things.

So, how does all this related to using your non-dominant hand? Sometimes the best position you can get into is going to be a compromise. I’m right handed, so I prefer to put femoral lines in standing on the patient’s right. But, that’s not always an option. Or if it is, the right femoral might not be good. So, I can reach over the patient to get to the left femoral, but that’s sometimes too much of a stretch (pun intended) and hurts my back). So, I can stand on the other side and twist myself to use my right hand, but that’s usually hard on my aging spine as well. So, I’ve developed the ability to go left-handed.

Similarly, I always teach to set your supplies on a table to your right (if you’re right handed) to do IJ line from the head of the bed. But, frequently in my place, that’s where the vent is and I might not be able to get a table there. So, I set my supplies up on the left. I can then twist and contort myself (a no-no), or I can use my left hand.

So, when you’re learning, learn with your dominant hand. But as you grow in your skills, branch out and learn to do some stuff with your non-dominant hand. It really comes in handy at times.

Zones of the Aorta

We’ve talked recently about the classification of aortic dissection based on location. But what if you want to be more specific about the location of an aortic injury? The Society of Thoracic Surgeons (STS) break the aorta down into 11 zones. Rishi Kumar explains the breakdown in this excellent diagram.

Lactate “Clearance”

We often trend lactate in critical illness. We use it as a marker of hypoperfusion in shock and as a guide to fluid volume resuscitation. But, why does it matter (or does it matter)? It’s pretty clear that elevated lactate in critical illness is not a great sign. But what does it mean and do we need to trend it? @eddyjoemd goes through the evidence for us, showing us why elevated lactate is bad and why we should trend it (or maybe why there really is a better trend we should be using instead).

Update: There is a great episode of his Saving Lives podcast on this as well. Just listened to it on my morning walk! Listen here.

Waveform Capnography

While we’ve used colorimetric capnography for years to confirm ETT placement, not all ICU providers are as familiar with waveform capnography. It offers significant benefits to the intubated and non-intubated patient alike.

Using waveform capnography to confirm ETT placement offers a benefit over colorimetric confirmation. during the peri-intubation period, while the patient is being ventilated via BVM, there can be an accumulation of CO2 in the stomach so that it is possible to get color change on an esophageal intubation. The use of waveform capnography prevents this. As carbon dioxide is not manufactured in the stomach, eventually the levels will fall. So, by trending the waveform over a few breaths, you should see a steady decrease in end-tidal CO2 over the course of a few breaths.

In addition to ETT positioning, ETCO2 has a number of other benefits including detecting displaced ETTs, monitoring effectiveness of ventilation in non-intubated patients, assessing ROSC during CPR, and much more. But essential to its use is understanding how to interpret the waveform and not just read the number. In this video, Obiajulu Anozie (@icuexplained) does a great job of explaining what the waveform means and how to use it in the ICU.

Death by Neurological Criteria

Otherwise known as “brain death,” death by neurological criteria was developed as a response to the development of advanced life support technology that was able to preserve vital functions despite devastating injury or illness. But, it is a confusing term and not just to families, but also to medical professionals who don’t deal with it on a regular basis. It is important to understand that “brain death” is no different than “cardiac death.” When discussing this with families, I like to explain, “if you were to have a massive heart attack and die, you don’t technically die because your heart stopped. You die because the brain dies. The brain dies because of lack of blood flow due to the fact that the heart has stopped.”

This may seem semantic, but it is an important note. Death is death, regardless of the proximate cause. Prior to the advent of advanced life support, people died of heart and lung failure before their brains failed. However, in the case of brain death, often brain injury is the proximate cause of death rather than secondary to the failure of other organ systems. There is often misunderstanding that “brain death” is not “real death” which can lead to the confusion among families that the medical team is “giving up.”

Recently, Dennis Kim shared an excellent article from the NEJM on Twitter regarding brain death determination that resulted in a good thread where providers who deal with this regularly share tips for having this conversation and performing this exam. Almost simultaneously, @pulmcritdoc shared this excellent summary on Instagram: