Part of the motivation of curating my Instagram account and my website to where it is today was to leverage the efforts of the nine lectures I am about to finish creating. These lectures are suitable for Continuing Medical Education, CME. They do not contain commercial bias. They should be eligible for AMA PRA Category 1 credits.

When I was in fellowship, I had to write several presentations but the most challenging tasks were writing grand rounds worthy presentations. I chose to do one of them on central line placement and infections, and the other lecture was on IV fluids. I figured I had two lectures pretty much complete but when I looked at my old work, I was gravely disappointed. They sucked. There was too much text on the slides, the presentations we’re as clean and neat as I would’ve like them to be. I was a bit all over the place.

Why I started Writing Continuing Medical Education Lectures

What good is it to do all this reading if you can’t teach other people with it? This is the masochist in me if you hadn’t realized it yet. A workhorse mentality is within me. Seeking new challenges is exciting. I sought out doing things I was uncomfortable with, i.e. public speaking.

I have a constant fear that the lectures are not going to be good enough.
In March of 2019 I went to a Critical Care Conference in Maui, HI for some CME. I went for two main reasons: it was in Hawaii so my wife and I would be able to leverage a vacation out of it, and that Dr. Paul Marik was also going to be there.

While at the presentation I realized several things. The first being that I had already read and dissected most of the articles presented on my own free time. There wasn’t much that I hadn’t been exposed to at one point or another. Also, I felt that, with the correct preparation, I could do the same or better at presenting data and material.

I took the initiative and went to find out who the directors of the program were to inquire if they were hiring. I provided some of my old (crappy) work and directed them to my YouTube channel where I had already built a catalog of sorts of content. Several weeks later, I was booked for August 2020 in Portland, OR. I was asked to submit ideas for 9-10 lectures. It was time to get to work!

Target Audience

The audience for whom I have written these lectures are for Intensivists, APPs, Pharmacists as they are extremely data heavy. At the end of the day, the lectures are very very nerdy but I have tried to put it together with a flow where they answer the clinical questions that you and I have always asked ourselves but haven’t quite had the chance to look those answers up. Well, I looked up all those answers.

I can easily adapt these lectures for training nursing staff as well as respiratory therapists who care more, and appropriately so, about the practical aspects of evidence-based medicine over, say, how a study was conducted and what the limitations are.

Ultimately, I do not want to bore anyone to death with my presentations. You will get credit for attending these lecture, though. They’re in a format that is acceptable for CME credit!

Leveraging the work

If you’re working really hard at something, you have to find a way to make the most of it. I have spent over a year of my life working on these 9 lectures. That is time that I wasn’t spending with my wife, my parents, my friends, and other ventures. When my Hawaii lectures were cancelled this month because of you-know-who, I didn’t pout or become disappointed. The time will come to let these babies breathe. And at the same time, I have been creating content for you all. Word on the stress is that they have benefitted the practice of many throughout the world. Flattering stuff. That’s far more beneficial that 100-300 people sitting in a conference room at a fancy hotel.

I have been able to leverage the work here on my website and Instagram. Although I have only put our a mere fraction of what I want to simply due to the time limitation.

Do you want me to speak at your facility/conference?

It’s time to take these lectures out on the road. It’s not optimal to be limited to working with that one company doing perhaps two conferences a year. I would like to share what I have learned with as many people as possible. I would be available to do Grand Rounds type presentations at academic and community hospitals throughout the country. After all, I generally work a 7on/7off schedule which allows me the ability to do a bit of traveling.

Metabolic Resuscitation

Anyone who knows my work over the last year is quite familiar with the fact that I am a fan of metabolic resuscitation. What is that, you ask? It is the utilizing stress dose steroids, thiamine, and vitamin c primarily as agents to help improve outcome to our patients who are in septic shock. This lecture is a biochemical and evidence-based journey into all of those who blindly say “it doesn’t work”. Truth is, I am 95% sure that those people have not looking into the data as deeply as they should before making such black and white statements.

Nonetheless, in this lecture I present my audience with that data explaining where we are, concerns, and limitations of using such cocktails. In addition, I also go down the rabbit hole of looking into melatonin, methylene blue, hydroxocobalamin, vitamin D, and XueBiJing as other agents we can potentially add to the mix to help improve survival in a disease process that accounts for 19.7% of all global deaths. Cutting edge content makes for the best continuing medical education. You won’t be bored.

Check out the many posts I have created on this topic.

Lactate and the Honeymoon Period: Is it the Boogeyman or an Alarm?

I frequently get called for “concerns” of patients who have an elevated lactate. I felt that it was necessary to present data where I explore the history and data behind using lactate as a surrogate for resuscitation. So much so that in addition I propose other mechanisms we can use to determine resuscitation success outside of using lactate that may be better for all of us.

In this lecture, I breakdown the biochemistry (I know, yuck, but I make it as fun as possible) of lactate metabolism. In addition, I present differentials, explain how to measure lactate appropriately, tackle honest questions about how to “clear lactate”, talk about ringer’s lactate and the whole “lactic acidosis created by LR” hubbub, and analyze if trending lactate actually improves mortality. I cap it off by looking at alternatives to trending lactate levels. I am prepared for a bunch of resistance to this talk haha. Can continuing medical education really change the way you think of things? This lecture will put that to the test.

Check out many posts that I have created on this topic.

Avoiding the Vent: High Flow Nasal Cannula and Non-invasive Ventilation

I make a living off of establishing airways and running ventilators (along with my trusty RT’s). I’d be much happier avoiding all that if possible. There’s much that can go wrong either during intubation, or while the patient is on the vent. After all, 30.7% of the people who are on mechanical ventilation die in the hospital.

In this lecture, I review the indications and data behind non-invasive ventilation (colloquially called BiPAP) in various scenarios. For the second part of my lecture, I do the same for high-flow nasal cannula.

Check out the many posts I have created on this topic.

Non-opioid Pain Management in the ICU

With all the societal issues of the opioid crisis, there has been a very large push towards making many things in the hospital setting opioid-free. I honestly feel that with the tools currently in our tool belt that we are doomed to fail at this. Opioids are the best medications for alleviating pain.

This doesn’t mean, though, that we can’t explore other options to try to mitigate its use or at least cut down on the doses provided. In this lecture, I explore alternative methodologies for controlling pain in the critically ill.
I go down the rabbit hole of NMDA antagonists such as ketamine and magnesium, IV lidocaine, gabapentinoids, dexmedetomidine, NSAIDS, acetaminophen, and regional anesthesia.

Check out the many posts I have created on this topic.

ICU Nutrition and Gut Health

I am quite the fan of nutrition in general but at the end of the day, I can only control my own nutrition when talking about the general population. But I can also control the nutrition of my critically ill patients! I became fascinated with this topic when I was a resident and have spent several years looking into it. Actually, this is one lecture that you can catch online on my YouTube channel: SEE IT HERE. I posted it to see how everyone would respond to it. Needless to say, it’s not my most popular video but I didn’t expect it to be, it’s rather niche.

I broke this lecture down into two parts: determining the best methods of providing nutrition to the critically ill as well as diving into the immunologic realm of the gut in the critically ill. I broke it down into a question/answer format because that’s how we generally look at thing.
– When to initiate?
– Early or delayed?
– Trophic or full nutrition?
– Enteral or parenteral?
– Should we provide nutrition to our patients in shock?
– What are the protein and calorie goals?
– Which formulas to use?
– How should we approach referring syndrome?
– Continuous or intermittent feeds?
When tackling the second part of the lecture, gut health, I look at the microbiome, probiotics, and fecal microbiota transplant to improve outcomes in our patients.

Check out many posts I have created on this topic.

Vasopressors in 2021

We use vasopressors daily in our ICUs to keep people alive, but at the end of the day our understanding is not as robust as we would like. We just listen to the Surviving Sepsis Guidelines and use Norepinephrine first followed by Vasopressin and then we call the chaplain after ordering whatever third vasopressor we fancy.
In this lecture I deconstruct norepinephrine, epinephrine, phenylephrine, dopamine, vasopressin/terlipressin/selepressin, angiotensin II, and midodrine.
More importantly, I attempt to answer the questions that we all ask ourselves like:
– Should we start norepinephrine early or after fluid resuscitation is complete?
– Which vasopressor to use in cardiogenic shock
– When to add on dobutamine?
– Why don’t we use phenylephrine in septic shock?
– Why all the hate for dopamine?
– Does renal dose dopamine actually work?
– Is vasopressin titrateable?
– In what order should we discontinue vasopressors?
– Any many more!
Needless to say, it’s a fun continuing medical education talk. I enjoyed putting it together very much.

Check out the many posts I have created on this topic.

IV Fluids in Resuscitation

This was one of the first lectures I ever wrote and I have been working on it constantly for the last 5 years. I remember getting pimped in my internal medicine residency while on my first ICU rotation and I did not know the contents of 0.9% NaCl. I was embarrassed. My attending, rightfully so, made me aware of the importance of knowing absolutely everything we put into the bodies of our patients. It was time to step up my game.

In this lecture, I review the differences between the types of IV fluids. The focus is on those fluids we use in resuscitation: 0.9% NaCl, Ringer’s Lactate, and Plasma-lyte. The lecture breaks down these fluids by components and dissect the studies that have shown them to be beneficial in their own certain sets of circumstances (except for saline, kidding-ish). I have grown weary of seeing so much hyperchloremic metabolic acidosis in patients who get transferred to the ICU volume overloaded and this is my attempt to fix it. I have also posted a substantial amount on Instagram regarding this.

Check out many posts that I have created on this topic

Resuscitation and Fluid Responsiveness

In this lecture I go over the concepts of fluids responsiveness and how, to the best of our knowledge and imperfect modalities, resuscitate our patients. What motivated me to work on this talk was the fact that I have seen too many patients in the course of my career get an excess of fluids in order to resuscitate their patients who are in shock. There has to be a better way to do this. I obviously touch on the adverse effects of drowning our patients but dive deeply into both the static and dynamic markers for resuscitation and fluid responsiveness.

For the static markers I go over CVP, ScvO2/SvO2, and IVC via POCUS. There are some who will say that IVC is a dynamic parameter but I disagree. A conversation for another day.

Within the dynamic parameters I go over passive leg raising combined with modalities to measure cardiac output, stroke volume, and end-tidal CO2. I also discuss PPV, SVV, echocardiographic principles like VTI, and end-expiratory occlusion pressure. There are many other variables that could be measured like global end-diastolic volume index, SVC diameter variation via a TEE and all that but let’s try to be realistic of what clinicians at non-Ivory tower facilities can realistically accomplish. This is some continuing medical education that we all desperately, myself included, need.

Check out many posts I have created on this topic.

Cardiogenic Shock: Rise of the Machines

I was very fortunate to have significant training in fellowship in a CCU and CVICU with mechanical circulator support. That’s where I grew to become quite the fan of the technology.

When starting my first job out of training, I learned that not everyone had the same familiarity nor shared the same enthusiasm. The issue is that these devices are only going to become more common. We are learning that adding additional vasopressors and inotropes doesn’t help. Well, you can argue that adding these devices doesn’t help either based on certain data. Mortality will get better as we become more familiar with them.

In this lecture I dissect the data behind mechanical circulatory support. This begins from a percutaneous perspective, including those that support the left heart. Devices such as IABP, Impella 2.5, CP, 5.0, TandemHeart, and VA-ECMO. I also dissect the data behind the devices that support the right heart. These devices include the Impella RP and the Protek Duo. Complications obviously need to be included and future studies as well as directions. This is some continuing medical education we all need.

Check out many posts that I have created on this topic.

These lectures are all breathing documents, I am constantly updating them with the newest evidence and publications. They should be applicable for continuing medical education credits. I have to credit Rob MacSweeny and his team over at criticalcarereviews.com for their weekly newsletter. It is invaluable to helping me obtain new data. Feel free to ask me any questions regarding all this or anything you’d like to see in my lectures.
– EJ

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