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
Reposted by josh farkas 💊
Individualized PEEP:
Can you estimate optimal PEEP in any BMI with the simple equation of BMI/3?
Maybe!
Our new paper comparing esophageal pressure base transpulmonary pressure estimates of optimal PEEP (tPP of 0 +\-2) vs BMI/3 in OR patients
www.sciencedirect.com/science/arti...
Can you estimate optimal PEEP in any BMI with the simple equation of BMI/3?
Maybe!
Our new paper comparing esophageal pressure base transpulmonary pressure estimates of optimal PEEP (tPP of 0 +\-2) vs BMI/3 in OR patients
www.sciencedirect.com/science/arti...
Identifying Optimal Positive End-Expiratory Pressure by Body Mass Index Does Not Account for Natural Physiologic Variability in Pleural Pressure
Mechanical ventilation and selecting optimal positive end-expiratory pressure (PEEP) in patients across a wide range of body mass indexes (BMI) is cha…
www.sciencedirect.com
November 13, 2025 at 7:41 PM
Individualized PEEP:
Can you estimate optimal PEEP in any BMI with the simple equation of BMI/3?
Maybe!
Our new paper comparing esophageal pressure base transpulmonary pressure estimates of optimal PEEP (tPP of 0 +\-2) vs BMI/3 in OR patients
www.sciencedirect.com/science/arti...
Can you estimate optimal PEEP in any BMI with the simple equation of BMI/3?
Maybe!
Our new paper comparing esophageal pressure base transpulmonary pressure estimates of optimal PEEP (tPP of 0 +\-2) vs BMI/3 in OR patients
www.sciencedirect.com/science/arti...
there's been LOTS of back-and-forth about vaso in sepsis
(e.g., these two 2025 review articles reach totally different conclusions! Lajoye is correct IMHO)
TLDR: there is no simple answer; personalize tx 🌌
my current take on vaso in sepsis is here: emcrit.org/ibcc/shock/#... #EMIMCC
(e.g., these two 2025 review articles reach totally different conclusions! Lajoye is correct IMHO)
TLDR: there is no simple answer; personalize tx 🌌
my current take on vaso in sepsis is here: emcrit.org/ibcc/shock/#... #EMIMCC
November 13, 2025 at 6:52 PM
there's been LOTS of back-and-forth about vaso in sepsis
(e.g., these two 2025 review articles reach totally different conclusions! Lajoye is correct IMHO)
TLDR: there is no simple answer; personalize tx 🌌
my current take on vaso in sepsis is here: emcrit.org/ibcc/shock/#... #EMIMCC
(e.g., these two 2025 review articles reach totally different conclusions! Lajoye is correct IMHO)
TLDR: there is no simple answer; personalize tx 🌌
my current take on vaso in sepsis is here: emcrit.org/ibcc/shock/#... #EMIMCC
Fresh IBCC: POCIT (Point-of-care infrared thermography)
This is basically where POCUS was 1995-2005
Technology & evidence-basis are improving
Early adopters may be interested
IMHO anything bringing us to the bedside more & forcing us to engage w/ the exam is good
emcrit.org/ibcc/pocit/ #EMIMCC
This is basically where POCUS was 1995-2005
Technology & evidence-basis are improving
Early adopters may be interested
IMHO anything bringing us to the bedside more & forcing us to engage w/ the exam is good
emcrit.org/ibcc/pocit/ #EMIMCC
November 13, 2025 at 2:00 PM
Fresh IBCC: POCIT (Point-of-care infrared thermography)
This is basically where POCUS was 1995-2005
Technology & evidence-basis are improving
Early adopters may be interested
IMHO anything bringing us to the bedside more & forcing us to engage w/ the exam is good
emcrit.org/ibcc/pocit/ #EMIMCC
This is basically where POCUS was 1995-2005
Technology & evidence-basis are improving
Early adopters may be interested
IMHO anything bringing us to the bedside more & forcing us to engage w/ the exam is good
emcrit.org/ibcc/pocit/ #EMIMCC
this is an ID fellowship, so the answer isn’t sarcoidosis 😳
#IDboardreview 25 yo M w/ recent tattoo (2 wks ago) now presents with this non-pruritic non-tender rash? Diagnosis? #medEd #IDMedEd #idsky
November 13, 2025 at 12:01 AM
this is an ID fellowship, so the answer isn’t sarcoidosis 😳
Reposted by josh farkas 💊
1/ 👋 there #neurotwitter #neurosky #neurocritcare, as part of my @neurocritcarej #SoMeAmbassador role, today we will be breaking down the following article: link.springer.com/ar...
November 12, 2025 at 9:01 PM
1/ 👋 there #neurotwitter #neurosky #neurocritcare, as part of my @neurocritcarej #SoMeAmbassador role, today we will be breaking down the following article: link.springer.com/ar...
Reposted by josh farkas 💊
Nothing normal about “normal” saline
-0.9% NaCl: 154 mEq Na + 154 mEq Cl. pH ~ 5.6
-Human/animal data shows it's proinflammatory
-SALT-ED (PMID:29485926) + SMART (PMID:29485925) show incr kidney injury w/ 0.9% NaCl vs balanced solutions
-LR more physiologic
youtube.com/shorts/XcV7R...
#EMIMCC
-0.9% NaCl: 154 mEq Na + 154 mEq Cl. pH ~ 5.6
-Human/animal data shows it's proinflammatory
-SALT-ED (PMID:29485926) + SMART (PMID:29485925) show incr kidney injury w/ 0.9% NaCl vs balanced solutions
-LR more physiologic
youtube.com/shorts/XcV7R...
#EMIMCC
Nothing Normal About "Normal" Saline #criticalcare #emergencymedicine #resuscitation
YouTube video by EMSwami
youtube.com
November 12, 2025 at 2:33 PM
Nothing normal about “normal” saline
-0.9% NaCl: 154 mEq Na + 154 mEq Cl. pH ~ 5.6
-Human/animal data shows it's proinflammatory
-SALT-ED (PMID:29485926) + SMART (PMID:29485925) show incr kidney injury w/ 0.9% NaCl vs balanced solutions
-LR more physiologic
youtube.com/shorts/XcV7R...
#EMIMCC
-0.9% NaCl: 154 mEq Na + 154 mEq Cl. pH ~ 5.6
-Human/animal data shows it's proinflammatory
-SALT-ED (PMID:29485926) + SMART (PMID:29485925) show incr kidney injury w/ 0.9% NaCl vs balanced solutions
-LR more physiologic
youtube.com/shorts/XcV7R...
#EMIMCC
IMHO the best strategy for occasional intubators (e.g., pulm/crit) is:
-Preox with BiPAP (PREOXY trial)
-Paralyze with roc/ketamine
-Intubate with hyperangulated VL + rigid stylet
This has a very sharp learning curve
Fellows can do this ~50 times and provide reproducibly safe intubations #EMIMCC
-Preox with BiPAP (PREOXY trial)
-Paralyze with roc/ketamine
-Intubate with hyperangulated VL + rigid stylet
This has a very sharp learning curve
Fellows can do this ~50 times and provide reproducibly safe intubations #EMIMCC
Hyperangulated videolaryngoscopy: stylet first until benefit of bougie is shown
"...the current challenge for the wider community of anaesthetists ... is not mastery of HAVL but access to devices, routine use, gaining familiarly and developing competence."
#AnSky
ttps://doi.org/10.1111/anae.70062
"...the current challenge for the wider community of anaesthetists ... is not mastery of HAVL but access to devices, routine use, gaining familiarly and developing competence."
#AnSky
ttps://doi.org/10.1111/anae.70062
November 10, 2025 at 1:27 PM
IMHO the best strategy for occasional intubators (e.g., pulm/crit) is:
-Preox with BiPAP (PREOXY trial)
-Paralyze with roc/ketamine
-Intubate with hyperangulated VL + rigid stylet
This has a very sharp learning curve
Fellows can do this ~50 times and provide reproducibly safe intubations #EMIMCC
-Preox with BiPAP (PREOXY trial)
-Paralyze with roc/ketamine
-Intubate with hyperangulated VL + rigid stylet
This has a very sharp learning curve
Fellows can do this ~50 times and provide reproducibly safe intubations #EMIMCC
I'm revising the IBCC septic shock chapter based on ANDROMEDA-SHOCK II
would love any feedback & critique on this
ANDROMEDA algorithm is nice, but it's too complicated for everyday use. We need something simpler.
& maybe it's time to push for IR thermography 😍
emcrit.org/ibcc/sepsis/... #EMIMCC
would love any feedback & critique on this
ANDROMEDA algorithm is nice, but it's too complicated for everyday use. We need something simpler.
& maybe it's time to push for IR thermography 😍
emcrit.org/ibcc/sepsis/... #EMIMCC
November 10, 2025 at 1:16 PM
I'm revising the IBCC septic shock chapter based on ANDROMEDA-SHOCK II
would love any feedback & critique on this
ANDROMEDA algorithm is nice, but it's too complicated for everyday use. We need something simpler.
& maybe it's time to push for IR thermography 😍
emcrit.org/ibcc/sepsis/... #EMIMCC
would love any feedback & critique on this
ANDROMEDA algorithm is nice, but it's too complicated for everyday use. We need something simpler.
& maybe it's time to push for IR thermography 😍
emcrit.org/ibcc/sepsis/... #EMIMCC
your daily reminder:
☕️ coffee is great
☕️ caffeine-free diets for hospitalized patients are silly & cause misery due to caffeine withdrawal #EMIMCC
☕️ coffee is great
☕️ caffeine-free diets for hospitalized patients are silly & cause misery due to caffeine withdrawal #EMIMCC
From @jama.com: Patients with #AFib who continued their usual caffeinated coffee intake after cardioversion experienced less recurrence of AF or atrial flutter compared to those who abstained from coffee and caffeine.
#AHA25 @ahascience.bsky.social
ja.ma/3XolIkd
#AHA25 @ahascience.bsky.social
ja.ma/3XolIkd
November 9, 2025 at 3:15 PM
your daily reminder:
☕️ coffee is great
☕️ caffeine-free diets for hospitalized patients are silly & cause misery due to caffeine withdrawal #EMIMCC
☕️ coffee is great
☕️ caffeine-free diets for hospitalized patients are silly & cause misery due to caffeine withdrawal #EMIMCC
this is really excellent.
I was drafting a blog post on ANDROMEDA-SHOCK-2 but this really covers what I was going to say, so I don't have to now.
I am still working on a simplified, pragmatic approach to apply this at the bedside... stay tuned. #EMIMCC
I was drafting a blog post on ANDROMEDA-SHOCK-2 but this really covers what I was going to say, so I don't have to now.
I am still working on a simplified, pragmatic approach to apply this at the bedside... stay tuned. #EMIMCC
Our latest blog is out:
Faith, Evidence and the Stars: The ANDROMEDA‑SHOCK‑2 Trial
https://criticalcarereviews.com/blog/current
Faith, Evidence and the Stars: The ANDROMEDA‑SHOCK‑2 Trial
https://criticalcarereviews.com/blog/current
November 8, 2025 at 4:49 PM
this is really excellent.
I was drafting a blog post on ANDROMEDA-SHOCK-2 but this really covers what I was going to say, so I don't have to now.
I am still working on a simplified, pragmatic approach to apply this at the bedside... stay tuned. #EMIMCC
I was drafting a blog post on ANDROMEDA-SHOCK-2 but this really covers what I was going to say, so I don't have to now.
I am still working on a simplified, pragmatic approach to apply this at the bedside... stay tuned. #EMIMCC
I'm updating the septic shock chapter to try to create a coherent & practical approach that incorporates Andromeda-2
Any great reviews, studies, or key points I should include? (Especially stuff that has come out within the past year)
Any great reviews, studies, or key points I should include? (Especially stuff that has come out within the past year)
a man is installing hardwood flooring in a living room with a drill .
ALT: a man is installing hardwood flooring in a living room with a drill .
media.tenor.com
November 8, 2025 at 1:28 PM
I'm updating the septic shock chapter to try to create a coherent & practical approach that incorporates Andromeda-2
Any great reviews, studies, or key points I should include? (Especially stuff that has come out within the past year)
Any great reviews, studies, or key points I should include? (Especially stuff that has come out within the past year)
my pressor strategy hepatorenal syndrome in the ICU:
#1) start with NE gtt for immediate BP target acquisition
#2) once pt is improving, use PO midodrine to accelerate weaning off NE
midodrine can be helpful to help liberate patients from ICU
but as initial therapy, midodrine is some weak sauce
#1) start with NE gtt for immediate BP target acquisition
#2) once pt is improving, use PO midodrine to accelerate weaning off NE
midodrine can be helpful to help liberate patients from ICU
but as initial therapy, midodrine is some weak sauce
Midodrine and octreotide should not be first line therapy for HRS-AKI #kidneywk
November 6, 2025 at 5:45 PM
my pressor strategy hepatorenal syndrome in the ICU:
#1) start with NE gtt for immediate BP target acquisition
#2) once pt is improving, use PO midodrine to accelerate weaning off NE
midodrine can be helpful to help liberate patients from ICU
but as initial therapy, midodrine is some weak sauce
#1) start with NE gtt for immediate BP target acquisition
#2) once pt is improving, use PO midodrine to accelerate weaning off NE
midodrine can be helpful to help liberate patients from ICU
but as initial therapy, midodrine is some weak sauce
Reposted by josh farkas 💊
#idboardreview 40 M presents w/ N, V, severe epigastric pain. SH:smoker, drinks 18 beers/day, monogamous with wife, bit by his dog 3d ago, dental cleaning 7d ago, recently installed air conditioning system. Bandemia, AKI. Diffuse blanching rash & mottling. Dx? #medEd #idmeded #idsky
November 6, 2025 at 12:13 AM
#idboardreview 40 M presents w/ N, V, severe epigastric pain. SH:smoker, drinks 18 beers/day, monogamous with wife, bit by his dog 3d ago, dental cleaning 7d ago, recently installed air conditioning system. Bandemia, AKI. Diffuse blanching rash & mottling. Dx? #medEd #idmeded #idsky
Reminder to discontinue A-lines when they are no longer needed.
Risk of infection is lower than with central lines (since A-lines usually stop working and get pulled relatively soon), but infection risk is real.
Risk of infection is lower than with central lines (since A-lines usually stop working and get pulled relatively soon), but infection risk is real.
Arterial catheter complications:
• 13/100 catheters failed for any reason
• 20/100 catheters failed for reasons not caused by infection
• bloodstream infections - 1/100 catheters
• local infections (around the area where the catheter goes in) - 1/100 cases
#ICUSky #AnSky
doi.org/10.1111/anae...
• 13/100 catheters failed for any reason
• 20/100 catheters failed for reasons not caused by infection
• bloodstream infections - 1/100 catheters
• local infections (around the area where the catheter goes in) - 1/100 cases
#ICUSky #AnSky
doi.org/10.1111/anae...
November 6, 2025 at 3:21 PM
Reminder to discontinue A-lines when they are no longer needed.
Risk of infection is lower than with central lines (since A-lines usually stop working and get pulled relatively soon), but infection risk is real.
Risk of infection is lower than with central lines (since A-lines usually stop working and get pulled relatively soon), but infection risk is real.
Reposted by josh farkas 💊
Incr safe apneic time important in improving 1st pass success
-Preox w/ NIV: Incr PaO2, recruit alveoli
-Oxygenate + intubate in Bed Up, Head Elevated
-Apneic O2 w/ flush rate NC
-Use rocuronium instead of succinylcholine (up to 45 sec more safe apneic time)
youtube.com/shorts/-3MFR...
#EMIMCC
-Preox w/ NIV: Incr PaO2, recruit alveoli
-Oxygenate + intubate in Bed Up, Head Elevated
-Apneic O2 w/ flush rate NC
-Use rocuronium instead of succinylcholine (up to 45 sec more safe apneic time)
youtube.com/shorts/-3MFR...
#EMIMCC
Safe Apneic Time #emergencymedicine #criticalcare #intubation #airway
YouTube video by EMSwami
youtube.com
November 5, 2025 at 3:03 PM
Incr safe apneic time important in improving 1st pass success
-Preox w/ NIV: Incr PaO2, recruit alveoli
-Oxygenate + intubate in Bed Up, Head Elevated
-Apneic O2 w/ flush rate NC
-Use rocuronium instead of succinylcholine (up to 45 sec more safe apneic time)
youtube.com/shorts/-3MFR...
#EMIMCC
-Preox w/ NIV: Incr PaO2, recruit alveoli
-Oxygenate + intubate in Bed Up, Head Elevated
-Apneic O2 w/ flush rate NC
-Use rocuronium instead of succinylcholine (up to 45 sec more safe apneic time)
youtube.com/shorts/-3MFR...
#EMIMCC
lung ultrasonography for nephrologists:
bilateral B-lines ➡️ keep spinning the dialysis machine thingy
A-lines & big pleural effusion ➡️ more fluid removal won’t immediately resolve the dyspnea (sometimes these are largely *uremic* effusions so aggressive volume removal can cause hypovolemia)
bilateral B-lines ➡️ keep spinning the dialysis machine thingy
A-lines & big pleural effusion ➡️ more fluid removal won’t immediately resolve the dyspnea (sometimes these are largely *uremic* effusions so aggressive volume removal can cause hypovolemia)
After a 40 minute handa on session where my station worked on kidney US we are back in the lecture room for a talk on lung ultrasound by Nathaniel Reisinger #KidneyWk
November 5, 2025 at 4:51 PM
lung ultrasonography for nephrologists:
bilateral B-lines ➡️ keep spinning the dialysis machine thingy
A-lines & big pleural effusion ➡️ more fluid removal won’t immediately resolve the dyspnea (sometimes these are largely *uremic* effusions so aggressive volume removal can cause hypovolemia)
bilateral B-lines ➡️ keep spinning the dialysis machine thingy
A-lines & big pleural effusion ➡️ more fluid removal won’t immediately resolve the dyspnea (sometimes these are largely *uremic* effusions so aggressive volume removal can cause hypovolemia)
Reposted by josh farkas 💊
This was a great case and discussion.
@pulmcrit.bsky.social your recent post also made me think of the case (where an MRI was indeed indicated, but not available for some time).
@pulmcrit.bsky.social your recent post also made me think of the case (where an MRI was indeed indicated, but not available for some time).
🚨New Neurology Podcast Episode 🚨
We continue our campaign to #EndNeurophobia, with the help of Dr. Aaron Berkowitz. This time, Dr. Yousuf Patel presents a case of diplopia & fever to Vale & Sebastian. 👀🧠
Listen here ➡️ clinicalproblemsolving.com/2025/11/02/e...
#MedSky #MedEd #Neurology #NeuroSky
We continue our campaign to #EndNeurophobia, with the help of Dr. Aaron Berkowitz. This time, Dr. Yousuf Patel presents a case of diplopia & fever to Vale & Sebastian. 👀🧠
Listen here ➡️ clinicalproblemsolving.com/2025/11/02/e...
#MedSky #MedEd #Neurology #NeuroSky
November 5, 2025 at 1:36 AM
This was a great case and discussion.
@pulmcrit.bsky.social your recent post also made me think of the case (where an MRI was indeed indicated, but not available for some time).
@pulmcrit.bsky.social your recent post also made me think of the case (where an MRI was indeed indicated, but not available for some time).
Reposted by josh farkas 💊
EMCrit Wee - @AndromedaShock 2 Explosion - An amazing discussion with the Lead Investigators. This conversation was educational and so enjoyable. Find out the intricacies of the study
[#FOAMed for now]
emcrit.org/as2-investi...
#edu_kattan
[#FOAMed for now]
emcrit.org/as2-investi...
#edu_kattan
November 4, 2025 at 6:01 PM
EMCrit Wee - @AndromedaShock 2 Explosion - An amazing discussion with the Lead Investigators. This conversation was educational and so enjoyable. Find out the intricacies of the study
[#FOAMed for now]
emcrit.org/as2-investi...
#edu_kattan
[#FOAMed for now]
emcrit.org/as2-investi...
#edu_kattan
Reposted by josh farkas 💊
#idboardreview 50 F recent dental infection presents 4d of fever, R headache, L weakness. MRI ring enhancing lesion & aspirate w/ GPC ‘balls of yarn’ 🧶 diagnosis? #medEd #idmedEd #IDsky
November 4, 2025 at 10:35 PM
#idboardreview 50 F recent dental infection presents 4d of fever, R headache, L weakness. MRI ring enhancing lesion & aspirate w/ GPC ‘balls of yarn’ 🧶 diagnosis? #medEd #idmedEd #IDsky
History lesson:
Neurology and neurologists predated the MRI scan.
It is possible to provide neurological care without getting an MRI on every single patient.
Neurology and neurologists predated the MRI scan.
It is possible to provide neurological care without getting an MRI on every single patient.
a man in a red suit and tie is holding a piece of paper that says breaking news on it
ALT: a man in a red suit and tie is holding a piece of paper that says breaking news on it
media.tenor.com
November 4, 2025 at 1:19 PM
History lesson:
Neurology and neurologists predated the MRI scan.
It is possible to provide neurological care without getting an MRI on every single patient.
Neurology and neurologists predated the MRI scan.
It is possible to provide neurological care without getting an MRI on every single patient.
Reposted by josh farkas 💊
Zarbock is a strange guy - he’s done a lot of positive kidney trials which others have not been able to replicate
I don’t believe any work if it only comes from that group
And the amino acid story is so implausible 🤷🏽♂️
I don’t believe any work if it only comes from that group
And the amino acid story is so implausible 🤷🏽♂️
November 3, 2025 at 10:49 PM
Zarbock is a strange guy - he’s done a lot of positive kidney trials which others have not been able to replicate
I don’t believe any work if it only comes from that group
And the amino acid story is so implausible 🤷🏽♂️
I don’t believe any work if it only comes from that group
And the amino acid story is so implausible 🤷🏽♂️
Reposted by josh farkas 💊
Endovasc Stroke Tx + Airway
-High risk airway decomp: High NIHSS, AMS or Posterior Stroke
-Etomidate a great agent: HD stable
-Avoid hypocarbia (cerebral vasoconstriction)
-After intubation, lie patient flat. Studies (PMID: 40465238) show improved outcomes
youtube.com/shorts/LChtQ...
#EMIMCC
-High risk airway decomp: High NIHSS, AMS or Posterior Stroke
-Etomidate a great agent: HD stable
-Avoid hypocarbia (cerebral vasoconstriction)
-After intubation, lie patient flat. Studies (PMID: 40465238) show improved outcomes
youtube.com/shorts/LChtQ...
#EMIMCC
Intubating in Large Vessel Occlusion Stroke #emergencymedicine #criticalcare #intubation
YouTube video by EMSwami
youtube.com
November 3, 2025 at 3:02 PM
Endovasc Stroke Tx + Airway
-High risk airway decomp: High NIHSS, AMS or Posterior Stroke
-Etomidate a great agent: HD stable
-Avoid hypocarbia (cerebral vasoconstriction)
-After intubation, lie patient flat. Studies (PMID: 40465238) show improved outcomes
youtube.com/shorts/LChtQ...
#EMIMCC
-High risk airway decomp: High NIHSS, AMS or Posterior Stroke
-Etomidate a great agent: HD stable
-Avoid hypocarbia (cerebral vasoconstriction)
-After intubation, lie patient flat. Studies (PMID: 40465238) show improved outcomes
youtube.com/shorts/LChtQ...
#EMIMCC
asking for a friend:
could we apply weight-based dosing to the cafeteria serving size?
could we apply weight-based dosing to the cafeteria serving size?
a black and white photo of a boy with the words please sir may i have some more below him
ALT: a black and white photo of a boy with the words please sir may i have some more below him
media.tenor.com
November 3, 2025 at 6:46 PM
asking for a friend:
could we apply weight-based dosing to the cafeteria serving size?
could we apply weight-based dosing to the cafeteria serving size?
our therapy dog posing as a lion wins halloween, thanks for playing everyone
October 31, 2025 at 4:31 PM
our therapy dog posing as a lion wins halloween, thanks for playing everyone