iiinova — where your digital self keeps evolving

josh farkas 💊 @pulmcrit.bsky.social · 02/09/2026

Fresh IBCC chapter on airway management: 🤿 Systematic pre-intubation evaluation, optimization, & checklist 🤿 BiPAP preoxygenation 🤿 HOB up, sniffing position 🤿 1st attempt with hyperangulated VL 🤿 Pulmonologist-style bronch for awake intubation emcrit.org/ibcc/tube/

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josh farkas 💊 @pulmcrit.bsky.social · 06/08/2026

Fresh Blog: Why I think hyperangulated VL should be the default for ICU intubations: 📹 People actually use the tool correctly 📹 Master one technique for easy & hard airways 📹 Compatible with steep bed angulation 📹 The fresh COVALENT MC-RCT 😁 #EMIMCC blog: emcrit.org/pulmcrit/hab...

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josh farkas 💊 @pulmcrit.bsky.social · 21/06/2026

Fresh Blog: Is oseltamivir assassinating ICU patients? ☠️ The REMAP-CAP trial has concluded with >98% certainty that oseltamivir is killing patients. ☠️ This is an extraordinary claim that requires extraordinary evidence. #1/2... #EMIMCC

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Anand Swaminathan @emswami.bsky.social · 10/06/2026

Nicardipine: great for htn emergency but, can see transient hypotension even w/ slow titration -Key is to load + drip -Start 5 mg/hr + titrate up 2.5 mg/hr q5 min -When reach target BP, drop dose back to 5 mg/hr + retitrate infusion until get to steady state youtube.com/shorts/2F0-1... #EMIMCC

youtube.com

Nicardipine Titration #emergencymedicine #criticalcare

YouTube video by EMSwami

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josh farkas 💊 @pulmcrit.bsky.social · 25/05/2026

Stop using IGRA to test for active pulmonary TB! this keeps coming up, so I summarized my take-home messages on this (with a link to the BlueSky discussion) in hospitals that lack deep experience with TB, I think the best heuristic is simply not to use an IGRA to look for active pulmonary TB

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josh farkas 💊 @pulmcrit.bsky.social · 21/05/2026

what is your best pearl, or most useful reference, about interpreting a complete blood count with differential? The blood count is one of the most commonly ordered tests in clinical medicine, but its subtleties are woefully overlooked. #EMIMCC

static.klipy.com

Inception: We Need To Go Deeper Meme with Leonardo DiCaprio

ALT: Inception: We Need To Go Deeper Meme with Leonardo DiCaprio

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josh farkas 💊 @pulmcrit.bsky.social · 14/05/2026

we’ve integrated the PREOXI trial into our practice so well that there’s an entire cabinet in our ICU dedicated to it 😁 this improves intubation success & safety. I’vd wanted to do this for a decade but the RCT provided EBM backing to push it forward more here emcrit.org/pulmcrit/bsi/

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josh farkas 💊 @pulmcrit.bsky.social · 09/05/2026

Proposal: for complex patients (eg ICU) we should *always* get CBC w/ differential (not a plain CBC) - Same amount of blood - Run by the same machine (it usually CHECKS the differential & just dumps the data!) - Trivial cost difference - Can be helpful (eg Eos 2/2 drug, NLR) #EMIMCC

static.klipy.com

Beelzebub's Interesting Proposal (Good Omens)

ALT: Beelzebub's Interesting Proposal (Good Omens)

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josh farkas 💊 @pulmcrit.bsky.social · 06/05/2026

everyone learns about TCA overdose in med school, but not bupropion XR overdose time to level up bupropion XR overdose is increasingly common & VERY dangerous ongoing drug absorption creates a "toxin bomb" wherein patients look OK initially, but deteriorate later on... (#1/2) #EMIMCC

static.klipy.com

CS:GO Bomb Defuse Timer Countdown Animation

ALT: CS:GO Bomb Defuse Timer Countdown Animation

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josh farkas 💊 @pulmcrit.bsky.social · 22/04/2026

one fun thing about using phenobarbital for seizures in ICU is that you can be as precise as you want (PK is predictable & levels turnaround fast) high precision usually isn't needed but if the neuro team wants me to hit a specific phenobarbital level in brittle SE, I'm on it 🫡. #EMIMCC

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josh farkas 💊 @pulmcrit.bsky.social · 18/04/2026

medicine of the PITT: status epilepticus in pregnancy if you're using levetiracetam as your go-to antiseizure med (as most folks are), then the treatment is essentially the same as usual add Mg, but Mg prevents sz recurrence (rather than lysing active sz) #1/2 #EMIMCC

media.tenor.com

a man with a stethoscope around his neck is sitting in front of a sign that says " only time will tell "

ALT: a man with a stethoscope around his neck is sitting in front of a sign that says " only time will tell "

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josh farkas 💊 @pulmcrit.bsky.social · 14/04/2026

is there a reason that we don't use more IV glycopyrrolate for status asthmaticus? admittedly minimal direct evidentiary support, but makes sense & indirect evidence seems more benign than various alternative treatments (eg intubation, ECMO, extracorporeal CO2 removal). #EMIMCC

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josh farkas 💊 @pulmcrit.bsky.social · 12/04/2026

I’m a proud brand ambassador for generic hospital scrubs™️ Hospital scrubs are laundered at higher temperatures than your home washer, making them cleaner. Hospital scrubs: ✅ Easy ✅ Clean ✅ Make your body look like a human blimp

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josh farkas 💊 @pulmcrit.bsky.social · 03/04/2026

Pet peeve: Research on pupillometry that only reports the neural pupil index (NPi) is worthless & will wind up in the ash heap of history. NPi is *proprietary* & calculated with a *secret* formula by *one* company's product. Does this seem like ideal scientific practice?...#1/2 #EMIMCC

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josh farkas 💊 @pulmcrit.bsky.social · 31/03/2026

note to self: use more IV nalbuphine it's supported by robust theoretical & clinical evidence I'm pretty sure the only reason we don't use it more often is due to our training and habits (habit-based practice, not evidence-based practice) esp. useful in patients with tenuous respiratory drive

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josh farkas 💊 @pulmcrit.bsky.social · 30/03/2026

Fresh blog on the HI-PEITHO trial 😁 🔊 ~18 mg alteplase over 7 hrs is safe (no ICH, no difference in bleeding rates) 🔊 Alteplase reduces the risk of cardiopulmonary decompensation and poor functional outcomes #1/2 #EMIMCC

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josh farkas 💊 @pulmcrit.bsky.social · 28/03/2026

it's hilarious watching people desperately try to apply the AHA/ACC risk stratification system to the HI-PEITHO trial HI-PEITHO was built off of the ESC risk-stratification system and it's impossible to map these patients onto the AHA/ACC classification. ESC is better. just use it.

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josh farkas 💊 @pulmcrit.bsky.social · 26/03/2026

missing sepsis - bad misdiagnosing another catastrophe as “sepsis” - also bad it almost makes me think that maybe we should specially train people how to identify and differentiate these disease processes and provide personalized care 🤔

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josh farkas 💊 @pulmcrit.bsky.social · 24/03/2026

kudos to ACEP for calling out the Surviving Sepsis Campaign 2026 guidelines and not joining in this madness. ACEP is great at making evidence-based policies that actually *help* provide better patient care. When ACEP is politely burning your guideline, you’re in trouble. #EMIMCC

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josh farkas 💊 @pulmcrit.bsky.social · 23/03/2026

Surviving Sepsis 2026 is here & it's even more loony tunes than I was expecting. They're promoting pre-hospital ABX & preemptive broad-spectrum IV antibiotics for intubated patients. This insane fever dream is an antimicrobial stewardship nightmare. Embarrassment for SCCM. #EMIMCC

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josh farkas 💊 @pulmcrit.bsky.social · 19/03/2026

If you missed this, read it before the HI-PEITHO trial comes out on 3/28 I think the STRATIFY trial will be integral to understanding and applying the results of the HI-PEITHO trial 😁🤞

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josh farkas 💊 @pulmcrit.bsky.social · 16/03/2026

Fresh blog: Six reasons to stop relying on the NPi (neurological pupil index) 👁️ NPi is based on a secret, proprietary formula used by one company 👁️ The neuroICU field was somehow convinced that we're too stupid to understand pupillometry tracings, so we need the NPi...(#1/2) #EMIMCC

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josh farkas 💊 @pulmcrit.bsky.social · 15/03/2026

proposal: IV lacosamide loading in the ICU is safe in patients with asymptomatic 1st degree AV block (PR >200 ms) I encounter a lot of anxiety surrounding this, but the fear doesn't seem to be evidence-based Other drugs we use in ICU are much more likely to cause bradycardia

media.tenor.com

a man in a suit and tie is sitting at a desk and says who hurt you

ALT: a man in a suit and tie is sitting at a desk and says who hurt you

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josh farkas 💊 @pulmcrit.bsky.social · 10/03/2026

Patient with pulmonary embolism develops mild hemoptysis: - Dont panic - Dont stop anticoagulation - Dont give TXA - Just continue anticoagulation Hemoptysis is an accepted symptom of PE. It’s usually due to mild capillary necrosis & not severe (not arterial).

media.tenor.com

a sign that says stay on target with a red line

ALT: a sign that says stay on target with a red line

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josh farkas 💊 @pulmcrit.bsky.social · 08/03/2026

New JAMA review attempts to equate pulmonary congestion with systemic congestion ("volume overload") This is sloppy & often wrong Pts w/ LV failure often have pulmonary congestion w/o systemic congestion Pts w/ RV failure usually have systemic congestion w/ dry lungs CVP isn't PCWP #EMIMCC

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josh farkas 💊 @pulmcrit.bsky.social · 08/03/2026

ScvO2 is so hot right now. About a decade ago we had a patient in shock with terrible echo windows. ScvO2 was high, so the team thought sepsis. Antibiotics failed. Autopsy showed MI. We had an M&M conference. Everyone was confused about why the ScvO2 misled us. What happened? … #1/2 #EMIMCC

media.tenor.com

a man in a suit and tie says what went wrong on snl

ALT: a man in a suit and tie says what went wrong on snl

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Dr. Timothy Fernandes, MD. MPH @drtimfernandes.bsky.social · 08/03/2026

The A-E categories are totally made up, based on retrospective data, difficult to apply clinical trials including data toward (ie intermediate-high risk spans multiple categories), and should not serve as the basis for determining whether an intervention is warranted.

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josh farkas 💊 @pulmcrit.bsky.social · 07/03/2026

Fresh blog: Four fatal flaws in the new AHA/ACC risk-stratification system for PE. The new AHA/ACC risk-stratification scheme is worse than the currently accepted one. Keep calm and carry on using your *current* risk-stratification system...(#1/2) #EMIMCC

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josh farkas 💊 @pulmcrit.bsky.social · 06/03/2026

Fresh blog: STRATIFY trial for PE Peripheral tPA infusion is EQUALLY EFFECTIVE as compared to ultrasound-assisted thrombolysis Catheter-directed thrombolysis for PE is dead We can get the same benefits with peripheral tPA infusions (w/o procedural costs & complications)... #1/2 #EMIMCC

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OLS @olofl-s.bsky.social · 05/03/2026

A woman in her 60s seeks the ED for 10/10 CP that lasted an hour. Now 1/10. Vitals, ECG unremarkable. #POCUS shows a dissection flap in the abdominal aorta. No pericardial effusion. CT confirms dissection from aortic valve to the iliac artery. Surgery successful, full recovery. #EMIMCC

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josh farkas 💊 @pulmcrit.bsky.social · 05/03/2026

PERT activation worksheet 😁 trying to design a one-page sheet to collect info & guide the process this is what I've got so far, please provide constructive feedback #EMIMCC

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josh farkas 💊 @pulmcrit.bsky.social · 23/02/2026

LENTZ EQUATION 🔥PEEP = BMI/3🔥 🙅‍♂️Stop under-PEEPing patients with high BMI 🙅‍♂️Stop trying to wean everyone down to a PEEP of 5 Patients with high BMI often need high PEEP as long as they are intubated & can be extubated *directly* off high levels of PEEP 😁 #EMIMCC

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josh farkas 💊 @pulmcrit.bsky.social · 16/02/2026

resident letting the first 10 drops of the lumbar puncture fall on the bed so they get a champaign tap

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Anand Swaminathan @emswami.bsky.social · 13/02/2026

Insulin bolus typically not necessary in DKA but, consider if: Delay in getting insulin drip from pharamacy. Severe acidosis: reach therapeutic levels faster + fix the acidosis faster Bolus dose: 0.1 U/kg youtube.com/shorts/pYybS... #EMIMCC

youtube.com

Insulin Bolus in DKA #criticalcare #emergencymedicine

YouTube video by EMSwami

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josh farkas 💊 @pulmcrit.bsky.social · 12/02/2026

this formula is clearly incorrect based on my high school science education you can't add a pressure and a velocity together because they have different units (mm, cm/s) if the units don't work, the formula must be invalid

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josh farkas 💊 @pulmcrit.bsky.social · 11/02/2026

it's wild how badly people dose hypertonic therapy 60 ml of 23% is equivalent to ~500 ml 3%, so this article makes no coherent sense best approach: figure out the sodium change you want and calculate the hypertonic dose math sets you free from dozens of contradictory consensus statements #EMIMCC

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josh farkas 💊 @pulmcrit.bsky.social · 10/02/2026

are you using a DEFCON-based strategy to manage bowel motility in hospitalized patients? having a clear, evidence-based treatment strategy improves efficacy & saves time you don't need to redesign the wheel for every patient & helpful to avert thermonuclear war emcrit.org/ibcc/constip... #EMIMCC

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josh farkas 💊 @pulmcrit.bsky.social · 09/02/2026

Fresh Blog: Mythbusting the use of beta-blockers for sinus tachycardia in thyroid storm This is one of the most dangerous & pervasive myths currently in circulation about acute care B-bl commonly precipitate shock or even arrest in these patients...(#1/2) blog: emcrit.org/pulmcrit/tst... #EMIMCC

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josh farkas 💊 @pulmcrit.bsky.social · 01/02/2026

@bradspellberg.bsky.social and other ID gurus - Does this look OK to you? Any critiques and/or additional thoughts you would pass along to front-line clinicians about implementing this regimen in real life? (disclosure: my hatred of ampho-induced AKI runs deep) emcrit.org/ibcc/cryptoc...

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josh farkas 💊 @pulmcrit.bsky.social · 31/01/2026

Updated the acute ischemic stroke chapter based on 2026 ASA/AHA guidelines Chapter focuses on supportive care (*not* who gets lysis/EVT) This has not changed very much Top blue numbered section is designed to be used as a checklist when you settle these pts into ICU emcrit.org/ibcc/ais/ #EMIMCC

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josh farkas 💊 @pulmcrit.bsky.social · 30/01/2026

The new 2026 AHA/ASA stroke guidelines include this table 👇 for the management of thrombolytic-induced angioedema. There is NO discussion or any additional text about this topic. I find this to be insufficient, not evidence-based, and potentially confusing... #1/2 #EMIMCC

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Infectious Diseases Fellowship at Indiana University @iuidfellowship.bsky.social · 28/01/2026

#idboardreview 20 F cough, F, fatigue didnt improve w/azithro, no travel,+gardening: wbc 17k 90%pmn, Ct patchy nodules biopsy necrotizing granulomas stain+Aspergillus. Growing up, pt &her brother had several episodes of cervical lymphadenitis. How to make dx of possible genetic dz? #idsky #idmeded

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Anand Swaminathan @emswami.bsky.social · 26/01/2026

Prolonged paralysis w/ rocuronium is an advantage -Once we decide to intubate, patient's getting tubed -W/sux, can end up in awake pt while trying to intubate if 1st/2nd attempt fail -W/ roc, plenty of time if you run into a challenging airway youtube.com/shorts/HXtN7... #EMIMCC

youtube.com

Roc + Prolonged Paralysis #criticalcare #emergencymedicine #intubation

YouTube video by EMSwami

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josh farkas 💊 @pulmcrit.bsky.social · 24/01/2026

reminder to liberally check carbon monoxide levels during snowmageddon CO levels can be measured on venous blood along with routine labs (no need for a separate arterial puncture) emcrit.org/ibcc/co/ #EMIMCC

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