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
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?
ordering a troponin, BNP, lactate, CRP, iCal, EEG, D-dimer, and panculture on a stable, long-stay ICU patient 5 minutes before your shift is over
a man in a nurse costume is walking down a street in front of an emergency sign
ALT: a man in a nurse costume is walking down a street in front of an emergency sign
media.tenor.com
December 26, 2025 at 3:32 PM
ordering a troponin, BNP, lactate, CRP, iCal, EEG, D-dimer, and panculture on a stable, long-stay ICU patient 5 minutes before your shift is over
interesting piece on gabapentin overutilization
thoughts
[1] gabapentin withdrawal is real; don't stop it cold turkey
[2] gabapentin is renally cleared; accumulation 2/2 AKI is a common cause of hypoactive delirium
[3] pregabalin has superior pharmacokinetics
www.msn.com/en-us/health... #EMIMCC
thoughts
[1] gabapentin withdrawal is real; don't stop it cold turkey
[2] gabapentin is renally cleared; accumulation 2/2 AKI is a common cause of hypoactive delirium
[3] pregabalin has superior pharmacokinetics
www.msn.com/en-us/health... #EMIMCC
MSN
www.msn.com
December 25, 2025 at 1:39 PM
interesting piece on gabapentin overutilization
thoughts
[1] gabapentin withdrawal is real; don't stop it cold turkey
[2] gabapentin is renally cleared; accumulation 2/2 AKI is a common cause of hypoactive delirium
[3] pregabalin has superior pharmacokinetics
www.msn.com/en-us/health... #EMIMCC
thoughts
[1] gabapentin withdrawal is real; don't stop it cold turkey
[2] gabapentin is renally cleared; accumulation 2/2 AKI is a common cause of hypoactive delirium
[3] pregabalin has superior pharmacokinetics
www.msn.com/en-us/health... #EMIMCC
Reposted by josh farkas 💊
D-dimer in PE: High false pos rate at standard thresholds
-Age-adjust(PMID: 24439717) + YEARS(PMID 28549662) incr threshold w/o incr miss rate
-Lancet Study(PMID: 41135553) simplifies: If PE isn’t most likely dx, double threshold
-0% miss rate w/ 19% decr CT
youtube.com/shorts/rfXcN...
#EMIMCC
-Age-adjust(PMID: 24439717) + YEARS(PMID 28549662) incr threshold w/o incr miss rate
-Lancet Study(PMID: 41135553) simplifies: If PE isn’t most likely dx, double threshold
-0% miss rate w/ 19% decr CT
youtube.com/shorts/rfXcN...
#EMIMCC
D-dimer in PE: Age-adjustment, YEARS etc #criticalcare #emergencymedicine
YouTube video by EMSwami
youtube.com
December 24, 2025 at 2:37 PM
D-dimer in PE: High false pos rate at standard thresholds
-Age-adjust(PMID: 24439717) + YEARS(PMID 28549662) incr threshold w/o incr miss rate
-Lancet Study(PMID: 41135553) simplifies: If PE isn’t most likely dx, double threshold
-0% miss rate w/ 19% decr CT
youtube.com/shorts/rfXcN...
#EMIMCC
-Age-adjust(PMID: 24439717) + YEARS(PMID 28549662) incr threshold w/o incr miss rate
-Lancet Study(PMID: 41135553) simplifies: If PE isn’t most likely dx, double threshold
-0% miss rate w/ 19% decr CT
youtube.com/shorts/rfXcN...
#EMIMCC
Holiday gift for ya: the IBCC chatbot app 😁
Free AI chatbot searches IBCC contents
Answers seem pretty good & it links to relevent chapters for additional info
Works as an Ebook index on steroids
Created by emergency med folks at Columbia (credit to Joshua Farber & David Fisher) #EMIMCC
Free AI chatbot searches IBCC contents
Answers seem pretty good & it links to relevent chapters for additional info
Works as an Ebook index on steroids
Created by emergency med folks at Columbia (credit to Joshua Farber & David Fisher) #EMIMCC
December 24, 2025 at 2:52 PM
Holiday gift for ya: the IBCC chatbot app 😁
Free AI chatbot searches IBCC contents
Answers seem pretty good & it links to relevent chapters for additional info
Works as an Ebook index on steroids
Created by emergency med folks at Columbia (credit to Joshua Farber & David Fisher) #EMIMCC
Free AI chatbot searches IBCC contents
Answers seem pretty good & it links to relevent chapters for additional info
Works as an Ebook index on steroids
Created by emergency med folks at Columbia (credit to Joshua Farber & David Fisher) #EMIMCC
I sometimes see folks recommending neuro checks for patients with neuromuscular disease (e.g., Guillain-Barre, myasthenia gravis)
this makes no sense to me
is there something I'm missing?
why would you do neurochecks for a neuromuscular disorder that doesn't involve the CNS? #EMIMCC
this makes no sense to me
is there something I'm missing?
why would you do neurochecks for a neuromuscular disorder that doesn't involve the CNS? #EMIMCC
December 22, 2025 at 10:35 PM
I sometimes see folks recommending neuro checks for patients with neuromuscular disease (e.g., Guillain-Barre, myasthenia gravis)
this makes no sense to me
is there something I'm missing?
why would you do neurochecks for a neuromuscular disorder that doesn't involve the CNS? #EMIMCC
this makes no sense to me
is there something I'm missing?
why would you do neurochecks for a neuromuscular disorder that doesn't involve the CNS? #EMIMCC
everyone predicting the end of medicine due to artificial intelligence 🙄
homer simpson from the simpsons is holding a sign that says the end is near
ALT: homer simpson from the simpsons is holding a sign that says the end is near
media.tenor.com
December 21, 2025 at 1:24 PM
everyone predicting the end of medicine due to artificial intelligence 🙄
Reposted by josh farkas 💊
Hypotension + Bradycardia: Updated Differential
-HyperK
-Beta blocker/CCB tox (can occur outside overdose)
-Clonidine or digoxin tox
-Blood in belly (vagal stim)
-Neurogenic shock
-Severe hypothyroid
-HyperMg
-Inferior MI
-Advanced AV blocks
-BRASH Syndrome
youtube.com/shorts/S3ibt...
#EMIMCC
-HyperK
-Beta blocker/CCB tox (can occur outside overdose)
-Clonidine or digoxin tox
-Blood in belly (vagal stim)
-Neurogenic shock
-Severe hypothyroid
-HyperMg
-Inferior MI
-Advanced AV blocks
-BRASH Syndrome
youtube.com/shorts/S3ibt...
#EMIMCC
Hypotension + Bradycardia #criticalcare #emergencymedicine #trauma
YouTube video by EMSwami
youtube.com
December 19, 2025 at 3:39 PM
Hypotension + Bradycardia: Updated Differential
-HyperK
-Beta blocker/CCB tox (can occur outside overdose)
-Clonidine or digoxin tox
-Blood in belly (vagal stim)
-Neurogenic shock
-Severe hypothyroid
-HyperMg
-Inferior MI
-Advanced AV blocks
-BRASH Syndrome
youtube.com/shorts/S3ibt...
#EMIMCC
-HyperK
-Beta blocker/CCB tox (can occur outside overdose)
-Clonidine or digoxin tox
-Blood in belly (vagal stim)
-Neurogenic shock
-Severe hypothyroid
-HyperMg
-Inferior MI
-Advanced AV blocks
-BRASH Syndrome
youtube.com/shorts/S3ibt...
#EMIMCC
Should we routinely provide fiber w/ enteral nutrition for critically ill patients?
Data is hard to interpret 2/2 variable treatments
But available RCTs suggest it's safe & beneficial
May support enterocytes & maintain microbiome
Giving a zero-fiber diet never made physiological sense #EMIMCC
Data is hard to interpret 2/2 variable treatments
But available RCTs suggest it's safe & beneficial
May support enterocytes & maintain microbiome
Giving a zero-fiber diet never made physiological sense #EMIMCC
December 18, 2025 at 1:19 PM
Should we routinely provide fiber w/ enteral nutrition for critically ill patients?
Data is hard to interpret 2/2 variable treatments
But available RCTs suggest it's safe & beneficial
May support enterocytes & maintain microbiome
Giving a zero-fiber diet never made physiological sense #EMIMCC
Data is hard to interpret 2/2 variable treatments
But available RCTs suggest it's safe & beneficial
May support enterocytes & maintain microbiome
Giving a zero-fiber diet never made physiological sense #EMIMCC
Reposted by josh farkas 💊
RSI Trial(PMID:41369227): Etomidate vs Ketamine
-No diff 28d mortality
-Incr HD collapse w/ ketamine (driven by incr/new pressors)
-Not clear why (More aggressive resus in etomidate group?)
-Forces us to reconsider our induction agent choice
youtube.com/shorts/CFWOR...
#EMIMCC
-No diff 28d mortality
-Incr HD collapse w/ ketamine (driven by incr/new pressors)
-Not clear why (More aggressive resus in etomidate group?)
-Forces us to reconsider our induction agent choice
youtube.com/shorts/CFWOR...
#EMIMCC
The RSI Trial: Etomidate vs Ketamine #criticalcare #emergencymedicine #intubation
YouTube video by EMSwami
youtube.com
December 17, 2025 at 3:31 PM
RSI Trial(PMID:41369227): Etomidate vs Ketamine
-No diff 28d mortality
-Incr HD collapse w/ ketamine (driven by incr/new pressors)
-Not clear why (More aggressive resus in etomidate group?)
-Forces us to reconsider our induction agent choice
youtube.com/shorts/CFWOR...
#EMIMCC
-No diff 28d mortality
-Incr HD collapse w/ ketamine (driven by incr/new pressors)
-Not clear why (More aggressive resus in etomidate group?)
-Forces us to reconsider our induction agent choice
youtube.com/shorts/CFWOR...
#EMIMCC
The CDC has approved ending blanket recommendations for HBV vax at birth 😩
Will hurt people & increase healthcare costs
Whether you care about humans or stocks, this is obviously dumb
Vaccination = huge return on financial investment
Healthy workforce = 🤑
Need to make this case to finance bros
Will hurt people & increase healthcare costs
Whether you care about humans or stocks, this is obviously dumb
Vaccination = huge return on financial investment
Healthy workforce = 🤑
Need to make this case to finance bros
a man wearing a headband says " use this " in front of a netflix sign
ALT: a man wearing a headband says " use this " in front of a netflix sign
media.tenor.com
December 17, 2025 at 1:30 PM
The CDC has approved ending blanket recommendations for HBV vax at birth 😩
Will hurt people & increase healthcare costs
Whether you care about humans or stocks, this is obviously dumb
Vaccination = huge return on financial investment
Healthy workforce = 🤑
Need to make this case to finance bros
Will hurt people & increase healthcare costs
Whether you care about humans or stocks, this is obviously dumb
Vaccination = huge return on financial investment
Healthy workforce = 🤑
Need to make this case to finance bros
if fentanyl is a weapon of mass destruction, I guess that makes me…..
Dr. Evil??
RELEASE THE FENTANYL
Dr. Evil??
RELEASE THE FENTANYL
a bald man is making a funny face and pointing at the camera with the words `` muhhaha '' .
ALT: a bald man is making a funny face and pointing at the camera with the words `` muhhaha '' .
media.tenor.com
December 17, 2025 at 2:27 AM
if fentanyl is a weapon of mass destruction, I guess that makes me…..
Dr. Evil??
RELEASE THE FENTANYL
Dr. Evil??
RELEASE THE FENTANYL
Reposted by josh farkas 💊
Does coffee lead to atrial fibrillation | The DECAF trial
You are at a conference. You had 1 glass of wine too many last night, so you had to add an extra coffee to get moving this morning. Then you feel a slight flutter in your chest. Caffeine is a stimulant, right? Could it be causing atrial…
You are at a conference. You had 1 glass of wine too many last night, so you had to add an extra coffee to get moving this morning. Then you feel a slight flutter in your chest. Caffeine is a stimulant, right? Could it be causing atrial…
Does coffee lead to atrial fibrillation | The DECAF trial
You are at a conference. You had 1 glass of wine too many last night, so you had to add an extra coffee to get moving this morning. Then you feel a slight flutter in your chest. Caffeine is a stimulant, right? Could it be causing atrial fibrillation? The paper Wong CX, Cheung CC, Montenegro G, Oo HH, Peña IJ, Tang JJ, Tu SJ, Wall G, Dewland TA, Moss JD, Gerstenfeld EP, Tseng ZH, Hsia HH, Lee RJ, Olgin JE, Vedantham V, Scheinman MM, Lee C, Sanders P, Marcus GM.
first10em.com
December 15, 2025 at 11:27 AM
Does coffee lead to atrial fibrillation | The DECAF trial
You are at a conference. You had 1 glass of wine too many last night, so you had to add an extra coffee to get moving this morning. Then you feel a slight flutter in your chest. Caffeine is a stimulant, right? Could it be causing atrial…
You are at a conference. You had 1 glass of wine too many last night, so you had to add an extra coffee to get moving this morning. Then you feel a slight flutter in your chest. Caffeine is a stimulant, right? Could it be causing atrial…
sedationists - any critique on this checklist for MidaKet procedural sedation?
basic explanation for MidaKet here: emcrit.org/pulmcrit/mid...
I'm usually using this for EGD, but many other uses
we often don't take EGD sedation too seriously, but a little extra care can avoid disaster #EMIMCC
basic explanation for MidaKet here: emcrit.org/pulmcrit/mid...
I'm usually using this for EGD, but many other uses
we often don't take EGD sedation too seriously, but a little extra care can avoid disaster #EMIMCC
December 15, 2025 at 3:39 PM
sedationists - any critique on this checklist for MidaKet procedural sedation?
basic explanation for MidaKet here: emcrit.org/pulmcrit/mid...
I'm usually using this for EGD, but many other uses
we often don't take EGD sedation too seriously, but a little extra care can avoid disaster #EMIMCC
basic explanation for MidaKet here: emcrit.org/pulmcrit/mid...
I'm usually using this for EGD, but many other uses
we often don't take EGD sedation too seriously, but a little extra care can avoid disaster #EMIMCC
1st, I review the resident note: it’s disorganized but OK
2nd, I review the med list. Every drug is perfectly dosed, timed, and routed. Totally optimized, tidy med list.
2nd, I review the med list. Every drug is perfectly dosed, timed, and routed. Totally optimized, tidy med list.
an elderly man is holding a credit card in his hand and looking at it .
ALT: an elderly man is holding a credit card in his hand and looking at it .
media.tenor.com
December 14, 2025 at 3:41 PM
1st, I review the resident note: it’s disorganized but OK
2nd, I review the med list. Every drug is perfectly dosed, timed, and routed. Totally optimized, tidy med list.
2nd, I review the med list. Every drug is perfectly dosed, timed, and routed. Totally optimized, tidy med list.
go home pharma, you’re drunk
December 13, 2025 at 1:09 PM
go home pharma, you’re drunk
Reposted by josh farkas 💊
Pericardial Tamponade: fix is drainage but resus prior focuses on full, fast + squeezed
#1: Full: Volume expansion
#2: Fast: Tachycardia helpful as increases cardiac output
#3: Squeezed: Use vasoactives to ensure adequate SVR + contractility (epi if bradycardic)
youtube.com/shorts/2Yth1...
#EMIMCC
#1: Full: Volume expansion
#2: Fast: Tachycardia helpful as increases cardiac output
#3: Squeezed: Use vasoactives to ensure adequate SVR + contractility (epi if bradycardic)
youtube.com/shorts/2Yth1...
#EMIMCC
Full Fast + Squeezed #criticalcare #emergencymedicine
YouTube video by EMSwami
youtube.com
December 12, 2025 at 2:35 PM
Pericardial Tamponade: fix is drainage but resus prior focuses on full, fast + squeezed
#1: Full: Volume expansion
#2: Fast: Tachycardia helpful as increases cardiac output
#3: Squeezed: Use vasoactives to ensure adequate SVR + contractility (epi if bradycardic)
youtube.com/shorts/2Yth1...
#EMIMCC
#1: Full: Volume expansion
#2: Fast: Tachycardia helpful as increases cardiac output
#3: Squeezed: Use vasoactives to ensure adequate SVR + contractility (epi if bradycardic)
youtube.com/shorts/2Yth1...
#EMIMCC
when I use etomidate, I generally add fentanyl (analgesia) & midaz (prolongs sedation >5 min & reduces risk of awareness)
I wonder what the BP difference is between ketamine vs an etomidate-midaz-fent cocktail?? 🤔
my guess would be: not much
don’t use pain as a pressor
I wonder what the BP difference is between ketamine vs an etomidate-midaz-fent cocktail?? 🤔
my guess would be: not much
don’t use pain as a pressor
December 11, 2025 at 11:13 PM
when I use etomidate, I generally add fentanyl (analgesia) & midaz (prolongs sedation >5 min & reduces risk of awareness)
I wonder what the BP difference is between ketamine vs an etomidate-midaz-fent cocktail?? 🤔
my guess would be: not much
don’t use pain as a pressor
I wonder what the BP difference is between ketamine vs an etomidate-midaz-fent cocktail?? 🤔
my guess would be: not much
don’t use pain as a pressor