Writing Notes

For better or for worse, a lot of our time in critical care in spent writing notes. in the US, these serve multiple purposes including communication, medico-legal documentation, and the basis for billing. But, I’ve found that the art of writing them is not really all that well taught. I can only speak of NP education first hand, first as a student and now as an educator, but anecdotally, I don’t think it’s much better in the MD/DO or PA worlds.

I was taught mostly by watching preceptors and reading their notes. That’s an OK strategy, except for 1) it places a lot of burden on the student to figure out why a note is good and how to adapt that to different situations, and 2) who’s to say that the preceptor is good at writing notes? I’ve had residents tell me before, “don’t worry about it. It doesn’t matter what you put in your note. No one really reads them.” But that’s wrong. On so many levels.

It does matter what your write (and how) and people do read your notes. for example, I read the notes of the people on my service who I’m following. I read the notes that consultants write, and I read the notes the primary service writes when I’m consulted on a patient. A well-written note is a great source of information and very helpful. A poorly written note can often me more of a hinderance than no note at all.

I’ve been wanting to write a Guide to Note Writing for a while, so I was really thrilled to see a great Twitter thread the other day from Robert Oubre covering this exact topic. I agree with everything he writes, so I’ll just let you read it for yourself. I will add this, your note is yours. There are right ways and wrong ways, but not one right way. The one constant I feel like I see (again, at least in NP education) is that people critiquing student notes often focus on the style points. The student doesn’t write the exact same way that they would. I’m always tempted to do this as well. I like the way I write and so I’d like if everyone else did the same. But, you’re a professional and should be able to find your own voice. But, this thread is gold.

Are Subclavian Lines Better than IJ Lines?

A friend of mine recently told me a story. He was told by someone that new best practice guidance was coming that the subclavian site is going to be the preferred site over the IJ. The reason for this is the decreased rate of infections at the subclavian site as compared to the IJ. I wasn’t able to verify this recommendation, but I can verify that subclavian lines have reduced rates of infection and clots. In a large, multi-center study in France, subclavian lines had a little fewer than half as many infections or clots (1.5 per 1000 catheter-days) as lines placed in the IJ (3.6 per 1000 catheter-days). And, IJ lines actually aren’t a lot better than femoral (4.6 per 1000 catheter-days). Additionally, you avoid several big problems (particularly in trauma and neuro patients) by not reducing venous drainage from the head or getting in the way of c-collars.

So, why don’t we all go for the subclavian as our first site of choice? Because we’re afraid of pneumothorax. That same French study found triple the rate of pneumothorax in subclavian lines (1.5%) as compared to IJ lines (0.5%). This is the reason we always hear for avoiding the subclavian site. But, I suspect that that pneumothorax rate is mostly related to technique. Whereas most IJ lines are placed with dynamic US guidance, most subclavian lines are placed using the old landmark technique. However, I had an attending teach me the US guided technique when I was a brand new NP and I regularly use it to place subclavian lines. Now, I still place far more IJ lines than subclavians, but I suspect that’s mostly habit.

It’s not a hard technique and I’ve had lots of success placing these lines with (so far, knock on wood) no pneumothoraces. How do you do it? Well, Josh Farkas over at PulmCrit has a great article detailing the use of US and the “shrug technique” for placing subclavian lines.

So, if the rate of infection and clots is so much lower (not to mention the other benefits) and we can reduce the rate of pneumothorax to an acceptable level, should subclavian be the site of choice? I mentioned that I wasn’t able to verify this rumor that the Best Practice guidelines were going to change, but, at least in Europe, there may be movement towards just that. The French Society of Intensive Care Medicine (SRLF), jointly with the French-Speaking Group of Paediatric Emergency Rooms and Intensive Care Units (GFRUP) and the French-Speaking Association of Paediatric Surgical Intensivists (ADARPEF) recently issued an expert consensus statement on management of intravascular catheters in the ICU. They make 2 interesting recommendations in this area: subclavian is the preferred site for central venous access, and IJ is probably not any better than femoral.

The American Society of Anesthesiologists, in Practice Guidelines for Central Venous Access 2020, cites the same data from the 2015 French study, but stops short of recommending subclavian over IJ, saying only, “in adults, select an upper body insertion site when possible to minimize the risk of infection.”

Where do you place your central lines? Do you use ultrasound? What are your thoughts on your current practice in light of this information?

Docusate for Constipation?

A while back, I read an article in a great series from the Journal of Hospital Medicine called, “Things We Do For No Reason” (and they have a Twitter account too!) It’s a great series and there are a lot of articles applicable to the ICU. The series examines things that we in healthcare do, but for which there is actually no good evidence for. The article in question was on the use of docusate for the prevention or treatment of constipation.

This is a drug that used to be on my standard ICU order set. Everyone got it on admission to prevent constipation. But, it turns out that it doesn’t really work. In fact, it’s no better than placebo. So, I stopped ordering it. I took it out of my order set. I use other drugs (like senna and polyethylene glycol) to prevent and treat constipation.

And so I was really glad to see this Instagram post from Doc Schmidt, an actual gastroenterologist also supporting the practice of ditching docusate! Check out his post and read the paper for yourself. Then delete that from your order set.

So, what’s the deal with therapeutic hypothermia?

Therapeutic hypothermia following cardiac arrest was a strategy to improve neurological outcomes first explored in 2002 following the publication of the publication of a trial by Bernard and colleagues in the NEJM. The theory was that metabolic demand slowed when the patient was placed in a hypothermic state. This would improve neurologic outcomes by reducing cerebral oxygen demand. It’s similar to the practice of cooling the patient during deep hypothermic circulatory arrest in the operating room for complex cardiac surgeries such as repair of the aortic arch.

The downside is, there are a number of major consequences and potential complications from hypothermia, as anyone who has treated environmental injuries associated with prolonged cold exposure can tell you. In the intervening 20 years since the initial Bernard study, a number of other studies have been published showing the benefit of cooling, but more than likely, no need for true hypothermia.

Bottom line, it seems that prevention of hyperthermia is probably just as beneficial and hypothermia, with far fewer deleterious effects. The University of Kentucky ICU Pharmacy recently did a great tweetorial summarizing the data surrounding hypothermia. Check it out for more details.

Goals of Care

Previously, we discussed how to deliver bad news. I set it up specifically as a situation that didn’t require much in the way of further discussion. The example I used was telling a family that their loved one had died. But often we have to have other types of difficult conversations with families as well. The most common type of this is the Goals of Care discussion.

This is a talk where you are delivering bad news of a sort, that their loved one is unlikely to have meaningful recovery. But in this conversation, there are decisions to be made. Unlike telling a family that someone has died, there isn’t total finality to this conversation. You need to help the family decide what to do next.

Often we consult palliative care for this, but I think that that is not the best practice for 2 reasons. First, any healthcare provider, especially an ICU provider, should be able to handle a basic goals of care discussion. Palliative care is helpful and should be involved in complex situations, especially those that involve tricky ethical or legal questions. But, the palliative care team is busy and just like you wouldn’t consult cardiology for every arrhythmia, you shouldn’t consult palliative for every goals of care discussion. Most often, people consult palliative care for these talks because they’re uncomfortable and the ICU provider would rather not have them.

And that brings me to reason number 2 to handle this without consulting palliative. It’s your responsibility. They are your patient and you shouldn’t abandon them when it becomes uncomfortable. In many cases, the ICU provider probably has some sort of relationship with the family (although not always, because patients may show up to the ICU in a non-salvageable condition). It’s going to better for the family to hear this from you than from a palliative care provider that they just met.

So, how do you approach this conversation? It’s similar to the breaking bad news discussion we talked about last time, but you often have a little advantage of prior relationship. I start by prefacing the conversation like this: “I’m going to speak very frankly to you because, if I were in your shoes, that’s how I’d want to be spoken to. I apologize if anything I say comes across as harsh, that’s not my intent. But, it’s been my experience that families prefer to get the straight truth rather than beating around the bush.” In several years, I’ve never had a family disagree.

Too often, we use medical jargon and euphemisms. Or, we just skirt around the issue without addressing it head on. I’ve been in conversations where the person leading the discussion does this and then leaves the room, feeling that they’ve been understood. But the family will walk away with a different understanding. “Your husband has had a very serious stroke and he’s not progressing like we had hoped. I think that looking at everything, the odds of him coming off the ventilator are very poor. It’s likely that he will never be much better than he is right now.”

The next thing to do is to discuss what the patient would value and how he or she would define quality of life. I know how I would want to live and how I would not want to live, but that isn’t for me to impose on others. For some people, if they could recognize their families, living in a nursing home on a ventilator might be something they’d be ok with. Others wouldn’t want to go on if they couldn’t be independent.

This is where predicting the future becomes tricky, but you need to lay out the best case scenario, the worst case scenario, and what you think is the most likely scenario. In some cases, the best case (which may still be a long shot) isn’t good enough for what they patient would want.

If the family indicates that the patient would not want to continue, this is when I lay out the options for end of life care. “We can transition to a different type of care in that case. One focused not on cure but on providing comfort and allowing a natural death.” I then will ask them if it’s ok for me to share with them what that looks like. This is all a lot to take in. Some families may need time to process. Simply hearing the poor prognosis may be enough. They may need time to come to grips with that before they’re ready to discuss comfort care.

Goals of care meetings may be one meeting where everything is decided, or they may take multiple days. You’ll need to gauge what they can handle. If they decide they want to continue, I describe the process of comfort care. “We stop doing tests and giving medicines that are not aimed specifically at comfort. Then, when you’ve had time to spend with them, the last step is to remove the breathing tube and take them off the ventilator.”

At this point, I usually ask if they’re waiting on other family members to arrive. If there are others coming within a reasonable amount of time (a few days), I suggest that we continue minimal life support (mechanical ventilation, vasopressors) to keep the patient stable until everyone has had a chance to arrive and say goodbye.

These are some of the most difficult conversations to have and can easily be the most exhausting part of your day. Despite what I said earlier, if you’re not comfortable with this conversation, call your palliative care team. But, use that as an opportunity to learn so that next time, you don’t have to call them. Once you do this a few times, you’ll get comfortable with it and it can become a very rewarding part of working in the ICU. If we only seeing curing patients as wins, then we lose a lot. And that can lead to burnout. However, if you take the view that we did everything we could and now we can focus on keeping them comfortable and allowing them to die with dignity, it can help turn what would normally be perceived as a negative outcome into a positive one.

Delivering Bad News

Having difficult conversations is probably the most overlooked, underappreciated skill in all of healthcare. Very few providers are taught this skill in any sort of structured way. It’s often something that they learn by watching others more senior to them. The problem with that is, those people learned it by watching people more senior to them, who learned it by watching…well, you get the idea. If whoever started the chain didn’t know how to do it, then bad habits kept getting passed down.

As a critical care nurse practitioner, I’ve been involved in hundreds of these conversations. And many of them were very poorly done. And it’s not just trainees. Some of the worst conversations were led by attending physicians with years of experience. And it’s not totally their fault. They were never taught how to do this.

I’ve had the good fortune to learn this skill from some excellent teachers. In school, during my trauma rotation, Dr Cindy Talley taught me how to deliver bad news to a family in a specific way, citing actual research in the field. As an NP, I’ve been fortunate to learn from some great palliative care providers like Dr Jessica McFarlin and see how to expand those principles into leading a goals of care discussion. Here’s how I approach the difficult conversation.

Delivering Bad News

This is the hardest conversation to have. When a patient has died, or is in a position where they are not going to survive, despite our best efforts. Often the difficulty is compounded by shock. Rarely are these expected.

Step 1: Just say it. In most of these cases, a family has been gathered together and placed in a room. They know very little except that their loved one is hurt or sick. Something bad has happened and they’re waiting to find out. The biggest mistake people make at this point is going into all the details. They won’t hear any of that because they’re waiting for the other shoe to drop. I quickly introduce myself and get right to the point.

“Your son was involved in a very serious car accident. He was brought in very badly hurt. We did everything we could. I’m very sorry, but he died.”

You have to say “died” (or “won’t survive if it’s imminent but hasn’t happened yet). Too often, we try to soften the blow by using euphemisms like, “passed” or “gone.” Although we know what we mean, in their worried state, the family can misunderstand that. There is a definite finality to the word death.

Step 2: Sit. This is when you need to shut up and resist the urge to say things or the (overwhelming) urge to leave). It will be uncomfortable. They may cry, they may scream. They will grieve and it will be awkward. But this is what they need to do right now. Let them.

Step 3: Questions. This is why you can’t run away during the grief. Because at some point, they will come around and they’ll be ready to hear all those details that you wanted to give at the start. They’ll have questions and it’s only after they’ve dealt with the initial shock that they can ask them.

That’s the basics of how to deliver bad news to a family. Next time, we’ll talk about how to have a goals of care conversation.

Working From Home

A lot of people are now working from home quite a bit due to the pandemic. It can be great at times (you can wear your pajamas! But, I guess most of us wear pajamas (aka scrubs) to work every day…) but there are definite challenges as well. I’m not great at it, but I’m getting better. For me, the biggest challenge are those days when the rest of my family is home as well. Jennifer Kanapicki Comer, MD wrote a really great piece for the Academic Life in Emergency Medicine (ALiEM) blog recently called The 1440 Doctor: How to Unplug While Working From Home. She discusses the challenges of working from home and how to deal with them (who knew that the lack of a commute could be a problem?). I’m trying to implement a lot of them (including implementing the WFH Commute) on days when I’m at home working on fellowship stuff, or teaching stuff, or this blog for example. Check it out, I think you’ll find it helpful!

Keeping Up with the “Literature,” Part 4

When I started this series of posts, I really thought it would be one additional post sharing some of my process, but it’s turned out to be a lot longer. I think that this will be the last one in the series (for now at least) and we’ll cover some practical tips for my 2 favorite resources, blogs and podcasts.


There are a ton of great blogs out there and I follow a bunch of them. Social media has the advantage of offering “quick bites” that can be scanned in a hurry and podcasts offer the ability to get educational content while doing other things (multi-tasking is always helpful in this busy world). But, blogs offer the distinct advantage of long-form, written content. Blogs can offer the space to really flesh out thoughts, link to other resources (including the original journal articles), and the ability to re-read passages for greater understanding.

The 2 biggest downsides for blogs are the length of time required to read posts and keeping track of all the content out there. The best tool I have found for dealing with both of these issues is an RSS reader. RSS readers allow you to subscribe to blogs and have content automatically delivered to you as soon as it’s released. There are a number of great options out there, I use one called Newsblur. I have it as an app on my phone, but it is also available as a website and tablet app. It’s simple and straightforward and free (my 2 big requirements). I can create categories for different blogs and then there are some categories that I review daily, some weekly, and some monthly. If I come across a post that interests me but I don’t have time to read it now, I can save it for later. I typically check this app daily and at least sort through what’s new and deciding if it’s something I’m interested in or not.


So, podcasts are far and away my favorite way to download (no pun intended) new info in terms of research and education. My favorite thing about podcasts is that they allow for multi-tasking. As I mentioned in an earlier post, I listen to podcasts while I mow my yard, while I walk my dog, and driving to and from work. This is a great time saver for me.

As far as organization, I just use the default Apple Podcasts app on my iPhone. I know that there are other options out there and have tried a few. But I keep coming back to Apple Podcasts. It’s simple and easy and free. The only thing I don’t love is that there is not a great way to organize podcasts. I’d like a way to categorize these, especially separating medical podcasts from those I listen to just for personal interests.

The last big trick I’ve started using with podcasts is adjusting the speed. This is something I had initially resisted because it felt weird. But, you get used to it and it becomes a helpful time saver. I typically listen to podcasts for fun at normal speed. If it’s a topic that I’m familiar with, I’ll listen at 1 1/2 x speed, sometimes rewinding and slowing down if I need to spend a little more intense concentration on a particular part. Sometimes I’ll listen to an episode at 2x speed if it’s a topic I know well and I just want to hear a particular take to see if I can recommend it to readers or students (but 2x does get sort of hard to listen to and understand if it’s at all complex). I’ll sometimes listen to Spanish podcasts at 1/2x speed to practice my Spanish skills.

Hopefully, this series has been helpful to you in terms of offering some more tools to keep up with the constant stream of critical care literature and education out there!

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.