josh farkas 💊
@pulmcrit.bsky.social
Pulm/crit attending at U. Vermont 🐄 Zentensivist 🧘♂️ trying to post more about medicine in order to distract myself from doomscrolling 🤦♂️ author of free online critical care textbook emcrit.org/ibcc/toc/ 📖 no conflicts of interest 💰
Pinned
josh farkas 💊
@pulmcrit.bsky.social
· Nov 28
PulmCrit: How to quickly create a useful professional account in BlueSky
I discussed the reasons for migrating to BlueSky here. I've received positive feedback from several FOAMed expats who migrated to Bluesky and enjoy it
emcrit.org
how to quickly set up a useful MedSky account!
🦋 Mix of basic & more advanced stuff (eg designing user-curated hashtag feeds)
🦋 Take a look & add any useful tips you have in the comments section
blog:
emcrit.org/pulmcrit/blu... #MedSky
🦋 Mix of basic & more advanced stuff (eg designing user-curated hashtag feeds)
🦋 Take a look & add any useful tips you have in the comments section
blog:
emcrit.org/pulmcrit/blu... #MedSky
resident letting the first 10 drops of the lumbar puncture fall on the bed so they get a champaign tap
February 16, 2026 at 3:01 PM
resident letting the first 10 drops of the lumbar puncture fall on the bed so they get a champaign tap
Reposted by josh farkas 💊
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
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
Insulin Bolus in DKA #criticalcare #emergencymedicine
YouTube video by EMSwami
youtube.com
February 13, 2026 at 2:49 PM
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
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
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
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
February 12, 2026 at 8:17 PM
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
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
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
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
February 11, 2026 at 9:15 PM
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
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
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
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
February 10, 2026 at 2:32 PM
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
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
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
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
February 9, 2026 at 2:30 PM
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
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
@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...
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...
February 1, 2026 at 5:14 PM
@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...
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...
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
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
January 31, 2026 at 7:26 PM
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
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
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
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
January 30, 2026 at 10:23 PM
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
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
Reposted by josh farkas 💊
#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
January 28, 2026 at 12:25 AM
#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
Reposted by josh farkas 💊
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
-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
Roc + Prolonged Paralysis #criticalcare #emergencymedicine #intubation
YouTube video by EMSwami
youtube.com
January 26, 2026 at 2:31 PM
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
-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
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
CO levels can be measured on venous blood along with routine labs (no need for a separate arterial puncture)
emcrit.org/ibcc/co/ #EMIMCC
January 24, 2026 at 5:53 PM
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
CO levels can be measured on venous blood along with routine labs (no need for a separate arterial puncture)
emcrit.org/ibcc/co/ #EMIMCC
does anyone know of a good iphone digital pupillometry app that doesn't store data in the cloud (i.e., doesn't have patient confidentiality issues)?
a close up of a human eye with brown eyes
ALT: a close up of a human eye with brown eyes
media.tenor.com
January 24, 2026 at 2:06 PM
does anyone know of a good iphone digital pupillometry app that doesn't store data in the cloud (i.e., doesn't have patient confidentiality issues)?
end-stage academia:
how to game the system to score more grants and publications
this is ultimately a zero-sum rat race that doesn't help patients or science
how to game the system to score more grants and publications
this is ultimately a zero-sum rat race that doesn't help patients or science
January 23, 2026 at 1:38 PM
end-stage academia:
how to game the system to score more grants and publications
this is ultimately a zero-sum rat race that doesn't help patients or science
how to game the system to score more grants and publications
this is ultimately a zero-sum rat race that doesn't help patients or science
🚨DCOS (delirium catatonia overlap syndrome)
~15% of critically ill delirious patients also have catatonia
treatment is different from isolated delirium (e.g., antipsychotics can *exacerbate catatonia*)
typical approaches to "delirium" are over-simplistic and mismanage these patients...(#1/2)
~15% of critically ill delirious patients also have catatonia
treatment is different from isolated delirium (e.g., antipsychotics can *exacerbate catatonia*)
typical approaches to "delirium" are over-simplistic and mismanage these patients...(#1/2)
January 17, 2026 at 12:49 PM
🚨DCOS (delirium catatonia overlap syndrome)
~15% of critically ill delirious patients also have catatonia
treatment is different from isolated delirium (e.g., antipsychotics can *exacerbate catatonia*)
typical approaches to "delirium" are over-simplistic and mismanage these patients...(#1/2)
~15% of critically ill delirious patients also have catatonia
treatment is different from isolated delirium (e.g., antipsychotics can *exacerbate catatonia*)
typical approaches to "delirium" are over-simplistic and mismanage these patients...(#1/2)
Reposted by josh farkas 💊
1/ Hello 👋 #medtwitter #neurotwitter #neurosky #medsky #neurocritcare #FOAMEd have another brief case that I wanted to discuss with you and see if maybe you can learn something new or reinforce old knowledge!
January 7, 2026 at 9:02 PM
1/ Hello 👋 #medtwitter #neurotwitter #neurosky #medsky #neurocritcare #FOAMEd have another brief case that I wanted to discuss with you and see if maybe you can learn something new or reinforce old knowledge!
basically every single article on external ventricular drains ever written:
neurology: "let us pontificate on the considerable bulk of data supporting rapid weaning strategies based on numerous outcome variables"
neurosurgery: "go kick rocks"
neurology: "let us pontificate on the considerable bulk of data supporting rapid weaning strategies based on numerous outcome variables"
neurosurgery: "go kick rocks"
January 10, 2026 at 3:16 PM
basically every single article on external ventricular drains ever written:
neurology: "let us pontificate on the considerable bulk of data supporting rapid weaning strategies based on numerous outcome variables"
neurosurgery: "go kick rocks"
neurology: "let us pontificate on the considerable bulk of data supporting rapid weaning strategies based on numerous outcome variables"
neurosurgery: "go kick rocks"
Senator Bill Cassidy is virtue signaling about how he is a doctor and how deeply he cares about protecting the health of children.
January 6, 2026 at 10:02 PM
Senator Bill Cassidy is virtue signaling about how he is a doctor and how deeply he cares about protecting the health of children.
antiseizure medications has a PK/PD profile similar to beta-lactam antibiotics:
-efficacy relates to the trough level
-toxicity relates to the peak level
so benefit/risk ratio is maximized with smaller, frequent dosing
hard to do outside the hospital re: adherence
but easy to do for inpatients
-efficacy relates to the trough level
-toxicity relates to the peak level
so benefit/risk ratio is maximized with smaller, frequent dosing
hard to do outside the hospital re: adherence
but easy to do for inpatients
a close up of a woman 's face with her eyes closed and her mouth open .
ALT: a close up of a woman 's face with her eyes closed and her mouth open .
media.tenor.com
January 6, 2026 at 1:43 PM
antiseizure medications has a PK/PD profile similar to beta-lactam antibiotics:
-efficacy relates to the trough level
-toxicity relates to the peak level
so benefit/risk ratio is maximized with smaller, frequent dosing
hard to do outside the hospital re: adherence
but easy to do for inpatients
-efficacy relates to the trough level
-toxicity relates to the peak level
so benefit/risk ratio is maximized with smaller, frequent dosing
hard to do outside the hospital re: adherence
but easy to do for inpatients
just replace the first year of medical school with a one-year course in hostage negotiation
a woman sitting next to a man with the words you negotiated that yeah
ALT: a woman sitting next to a man with the words you negotiated that yeah
media.tenor.com
January 5, 2026 at 2:22 PM
just replace the first year of medical school with a one-year course in hostage negotiation
I will be overhauling the neurology IBCC chapters this year
if you have any great review articles or books that I should include, let me know
if you have any great review articles or books that I should include, let me know
December 31, 2025 at 12:53 PM
I will be overhauling the neurology IBCC chapters this year
if you have any great review articles or books that I should include, let me know
if you have any great review articles or books that I should include, let me know
updated the IBCC chapter on BRASH
added a treatment checklist that walks you through resus of a sick BRASH pt
BRASH is uncommon & there are lots of moving pieces, so the checklist is a helpful cue to provide comprehensive treatment of all the BRASH components
emcrit.org/ibcc/brash/ #EMIMCC
added a treatment checklist that walks you through resus of a sick BRASH pt
BRASH is uncommon & there are lots of moving pieces, so the checklist is a helpful cue to provide comprehensive treatment of all the BRASH components
emcrit.org/ibcc/brash/ #EMIMCC
December 30, 2025 at 1:27 PM
updated the IBCC chapter on BRASH
added a treatment checklist that walks you through resus of a sick BRASH pt
BRASH is uncommon & there are lots of moving pieces, so the checklist is a helpful cue to provide comprehensive treatment of all the BRASH components
emcrit.org/ibcc/brash/ #EMIMCC
added a treatment checklist that walks you through resus of a sick BRASH pt
BRASH is uncommon & there are lots of moving pieces, so the checklist is a helpful cue to provide comprehensive treatment of all the BRASH components
emcrit.org/ibcc/brash/ #EMIMCC
IBCC service update:
Checklists are being converted to numbered grey subsections
These are intended to function as a checklist to guide real-time patient management
Advantages:
☑️easier to read on phone
☑️more flexible (can include images/links)
☑️can be read & used by LLMs
Checklists are being converted to numbered grey subsections
These are intended to function as a checklist to guide real-time patient management
Advantages:
☑️easier to read on phone
☑️more flexible (can include images/links)
☑️can be read & used by LLMs
December 28, 2025 at 2:03 PM
IBCC service update:
Checklists are being converted to numbered grey subsections
These are intended to function as a checklist to guide real-time patient management
Advantages:
☑️easier to read on phone
☑️more flexible (can include images/links)
☑️can be read & used by LLMs
Checklists are being converted to numbered grey subsections
These are intended to function as a checklist to guide real-time patient management
Advantages:
☑️easier to read on phone
☑️more flexible (can include images/links)
☑️can be read & used by LLMs
New York state just recorded the highest number of flu cases in a week since it started recording in 2004.
😳
This includes the 2009 H1N1 pandemic (I was a pulm fellow in NY then and it wasn't a great time).
😳
This includes the 2009 H1N1 pandemic (I was a pulm fellow in NY then and it wasn't a great time).
December 27, 2025 at 7:01 PM
New York state just recorded the highest number of flu cases in a week since it started recording in 2004.
😳
This includes the 2009 H1N1 pandemic (I was a pulm fellow in NY then and it wasn't a great time).
😳
This includes the 2009 H1N1 pandemic (I was a pulm fellow in NY then and it wasn't a great time).
has there ever been a high-quality RCT that demonstrated clinically meaningful benefits from pulse-dose steroid (e.g., 500-1000 mg/day methylprednisolone) as compared to a moderate dose of steroid (e.g., 1-2 mg/kg/day prednisone)?
for *any* disease?
for *any* disease?
a man in a suit and tie is standing in front of a blackboard with the words " anyone ? anyone ? "
ALT: a man in a suit and tie is standing in front of a blackboard with the words " anyone ? anyone ? "
media.tenor.com
December 26, 2025 at 5:17 PM
has there ever been a high-quality RCT that demonstrated clinically meaningful benefits from pulse-dose steroid (e.g., 500-1000 mg/day methylprednisolone) as compared to a moderate dose of steroid (e.g., 1-2 mg/kg/day prednisone)?
for *any* disease?
for *any* disease?