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josh farkas 💊

@pulmcrit.bsky.social

7.9K followers 360 following 1.5K posts

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 💰

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josh farkas 💊 @pulmcrit.bsky.social · Nov 28

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

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

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josh farkas 💊 @pulmcrit.bsky.social · 1h

normal mentation *doesn't* indicate adequate systemic perfusion

especially in cardiogenic shock, people can mentate well despite terrible CO & systemic perfusion

poor mentation is sometimes an early sign of *septic* shock, but often a very late indicator of other shock states #EMIMCC

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josh farkas 💊 @pulmcrit.bsky.social · 6h

this is only transiently used in the hospital until the patient is stabilized then consolidate the dose and give it less frequently

josh farkas 💊 @pulmcrit.bsky.social · 1d

pharmacokinetics trick:

let’s say a med (eg metoprolol) is used q12hr as an outpatient

if you’re worried about causing instability, you *can* cut the dose in half and give it q6hr

there is no law that it MUST be given q12hr

smaller intervals = smoother effect & greater titratability

#EMIMCC

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josh farkas 💊 @pulmcrit.bsky.social · 3d

Agree, but this requires a system-level intervention.

I didn’t put much stuff in the chapter about exactly how to titrate the insulin gtt because its generally best to use your local insulin gtt protocol that folks are comfortable with.

josh farkas 💊 @pulmcrit.bsky.social · 3d

Belmont is awesome 😁

josh farkas 💊 @pulmcrit.bsky.social · 3d

The difference between an expert vs amateur DKA resus is really efficiency

Patients are overwhelmingly likely to do well regardless

Expert resus may accelerate resolution & avoid re-opening the gap

So there are other hills to die on

If your protocols work efficiently, there’s no reason to change

josh farkas 💊 @pulmcrit.bsky.social · 3d

Updated the IBCC DKA chapter 🍭

Biggest changes were organizational, there is now a pretty clear & streamlined 8-step guide

Biggest content change was a rewrite of the definition of DKA (but - spoiler alert - the definition remains unclear & controversial)…

emcrit.org/ibcc/dka/#top #EMIMCC

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josh farkas 💊 @pulmcrit.bsky.social · 4d

got it thanks🙏🙏🙏

josh farkas 💊 @pulmcrit.bsky.social · 4d

Fresh blog: Six pearls on heparin-induced thrombocytopenia (HIT) in 2025

💎 enoxaparin causes 10x less HIT than UFH

💎 HEP score

💎 approach to intermediate 4T score?

💎 rising use of DOACs

💎 autoimmune HITT

💎 IVIG for immediate inhibition of HIT antibodies

blog emcrit.org/pulmcrit/hit... #EMIMCC

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Reposted by josh farkas 💊

Anand Swaminathan @emswami.bsky.social · 5d

Blunt Cardiac Injury
Suspect: blunt traumatic hemothorax, pulmonary contusions, esophageal/aortic injury
Not assoc w/ isolated sternal fracture
w/u: Tn and ECG - If either abnormal, admit to tele and get a comprehensive echo looking for wall motion abnormality

youtube.com/shorts/UTHbm...
#EMIMCC

Blunt Cardiac Injury #emergencymedicine #criticalcare #trauma

YouTube video by EMSwami

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josh farkas 💊 @pulmcrit.bsky.social · 5d

my favorite is the "consistent carb diet" where you're allowed to have a lot of carbs, or a little carbs, but it has to be consistent across the day 😂

josh farkas 💊 @pulmcrit.bsky.social · 5d

it's hard to fight city hall.

and nearly all of this BS won't really hurt people, it just delays their recovery

that's not great, but there are other hills to die on 🤷‍♂️

josh farkas 💊 @pulmcrit.bsky.social · 5d

we're seeing *lots* of cocaine & methamphetamine use, especially via inhalational routes

presentations vary, including:

🥵 acute agitation/psychosis
🥵 seizures
🥵 vascular events, esp in young people (stroke, MI)

Local news www.wcax.com/2025/10/02/v...

IBCC chapter emcrit.org/ibcc/symp/ #EMIMCC

Vermont health officials alarmed by shift from opioid abuse to stimulants

Vermont health officials say the state is entering a new wave of the drug crisis.

www.wcax.com

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Reposted by josh farkas 💊

Infectious Diseases Fellowship at Indiana University @iuidfellowship.bsky.social · 6d

#idboardreview 65 F HTN, smoker, no travel, no animal exposure, recurrent UTI on nitrofurantoin presents w/ 3d of illness, 101F, dry cough, dyspnea, now in respiratory failure. b/l crackles, BAL 12% eosinophils. dx? #medEd #idmedEd #IDtwitter #idsky pic for Ref only

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Reposted by josh farkas 💊

EMCrit Blog and Podcast @emcrit.bsky.social · 6d

EMCrit 409 - Pulmonary Embolism (PE) Update 2025 with @klinelab (Jeff Kline)
We explore some of the questions raised by the recently posted PE malpractice case.
When can you PERC???
Should you give heparin at the same time as your lytics?
and so much more
[#FOAMed for a bit]
emcrit.org/409

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josh farkas 💊 @pulmcrit.bsky.social · 6d

Agree, but you can order a regular diet and allow the patient to select their own carb-restricted foods.

Ordering a regular diet is simply giving the patient power to order whatever they want from the menu.

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josh farkas 💊 @pulmcrit.bsky.social · 6d

be kind and give your patients a REGULAR DIET

caffeine-free diets ➡️ caffeine withdrawal

sodium-restricted diets aren't evidence-based (use diuretics to balance volume)

treat hyperglycemia with insulin (not by artificially restricting carbs)

(renal diet for hyperkalemic renal failure = exception)

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josh farkas 💊 @pulmcrit.bsky.social · 6d

yeah I agree, if the heart rate is generally running <130s I’ll let it run free

sometimes shifting pressors to phenyl/vaso can buy you a little reduction in HR

if consistently >130 I’d probably add amiodarone

not aware of any good data on this

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Pulm PEEPS @pulmpeeps.bsky.social · 7d

🚨🔊 New episode out today! Case files at KUMC!

A 26 year old non-smoking man who immigrated from India and now lives in the mid-west US presents with a generalized tonic-clonic seizure in the setting of 6 months of cough and dyspnea. Here is the initial CT

#Pulmonary
#CriticalCare
#MedicalEducation

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Reposted by josh farkas 💊

Anand Swaminathan @emswami.bsky.social · 7d

IV insulin is a backbone tx in hyperK
Standard: 10 units IVP w/ dextrose
2021 meta(PMID: 33993515) looked at 10 units vs < 10 units
No difference in reduction in serum K.
Reduced risk of hypoglycemic + severe hypoglycemic events w/ reduced insulin dose

youtube.com/shorts/Sz9Zy...
#EMIMCC

Reduced Dose Insulin in HyperK #emergencymedicine #criticalcare

YouTube video by EMSwami

youtube.com

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josh farkas 💊 @pulmcrit.bsky.social · 8d

These sort of guidelines are actually holding back the field of DKA from making progress

because UpToDate and most other sources will mirror their recs off the guideline without much critical evaluation

josh farkas 💊 @pulmcrit.bsky.social · 8d

I'm pretty sure what they're trying to say is that the bicarbonate may remain low after the ketoacidosis has resolved due to a hyperchloremic NAGMA resulting from NaCl administration. I've read a ton of these reviews on DKA and most reviews will include a statement to this effect in this location 🤷‍♂️

josh farkas 💊 @pulmcrit.bsky.social · 9d

if you’re getting a CT chest for a critically ill patient in respiratory failure of unclear etiology, it should be a CT angio to evaluate for PE (& other stuff)

sometimes being thorough is more effective than being smart

also, contrast allows evauation of cardiac chamber size & IVC reflux

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josh farkas 💊 @pulmcrit.bsky.social · 10d

the guidelines also state that NAGMA isn't a big deal

but you're not supposed to stop the insulin drip until the bicarb is >18

if NAGMA prevents you from shutting off the insulin infusion, it will keep patients on the drip longer - which *absolutely* matters (time, $$$, bed utilization).

josh farkas 💊 @pulmcrit.bsky.social · 10d

I don't have time to catalog every error in the guidelines, but let me just mention a few.

the guidelines seem to lack an understanding of basic acid-base principles

for example, it says here that hyperchloremic metabolic acidosis from NaCl causes an elevation in anion gap.

nope, that's wrong.

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