REBEL MIND: The Power of Performance Coaching in Medicine

🧭 REBEL Rundown 📝Introduction Welcome to this special edition of the REBEL Cast, where we unravel key highlights and educational insights from the IncrEMentuM Conference in Spain. This event is a cornerstone for advancing emergency medicine education, drawing esteemed speakers and participants from around the globe. As emergency medicine gains traction in Spain, this conference has become an essential platform for knowledge exchange and professional growth. Today, host Dr. Mark Ramzy shines a spotlight on two phenomenal educators: Drs. Sara Crager and Ryan Ernst who shared their expertise and experiences at this transformative gathering last spring. Click here for Direct Download of the Podcast. 🤔What's IncrEMentuM? A new conference and a pivotal gathering for emergency medicine professionals worldwide, has become an essential platform for education, collaboration, and advocacy, especially in light of emergency medicine’s recent recognition as a specialty in Spain. The conference is praised for its outstanding production quality, engaging speakers, and its capacity to foster a global community of emergency care professionals. ️What's an Essential Question? Essential questions are open-ended, thought-provoking, and intellectually engaging inquiries that inspire deeper exploration into topics. In the context of medical education, they challenge practitioners to think critically and reflect on their practice deeply. By focusing on essential questions, medical educators aim to inculcate a culture of continuous learning and curiosity, ensuring that medical professionals stay adaptable and insightful in their approach to patient care. 🎮Rapid Sequence (no not the intubating style...)  The Rapid Sequence game is an innovative tool that Sara and Ryan designed to enhance the learning experience for emergency medicine clinicians. It mimics real-life scenarios requiring rapid decision-making in high-pressure situations, such as those faced in emergency medical settings. This clinical case-based game aims to improve cognitive and procedural skills, allowing participants to hone their ability to respond effectively under pressure, thereby enhancing their real-world clinical performance.You can try it out for free on their website here!Their work was featured in the September 2025 edition of Annals of Emergency Medicine as a 2025 ACEP Abstract 🌳The Arboretum Teaching Collective An arboretum is a space that cultivates a wide variety of diverse, unique, and symbiotic growth. Arboretum provides a creative space to decrease barriers, open opportunities, and support the development of extraordinary teachers. The Arboretum Teaching Collective is a non-profit organization dedicated to supporting emergency medicine education in countries where it is a new or evolving specialty.  Their aim to facilitate the development of expert teachers by reducing barriers, providing opportunities, and curating talent.  Their goal is to create a community of educators around the globe who share a vision of bringing excellent, innovative emergency medicine teaching to where it is most needed.  Their approach is driven by curiosity, humility, and sustainability.If you want to learn more and get involved, check out the Arboretum Teaching Collective Website Here ️ See you in Spain! The upcoming conference aims to gather world-class educators once more and promises an enriching experience for all attendees. Drs. Sara Crager and Ryan Ernst, along with many others, will be there at the event. For more information on the IncrEMentuM Conference and to register, visit their website! See you there! Sara Crager, MD Associate Professor, Critical Care and Emergency Medicine UCLA, Los Angeles, CA Ryan Ernst, MD Assistant Professor of Emergency Medicine, Section Chief of Global EM University of Utah, Salt Lake City, UT Mark Ramzy, DO Co-Editor-in-Chief Rutgers Health / RWJBH, Newark, NJ 🔎 Your Deep-Dive Starts Here REBEL CAST – IncrEMentuM26 Speaker Spotlight : Drs. Sara Crager and Ryan Ernst Host Dr. Mark Ramzy shines a spotlight on two phenomenal ... Resuscitation Read More REBEL CAST – IncrEMentuM26 Speaker Spotlight : Drs. Tarlan Hedayati, Jess Mason and Simon Carley Host Dr. Mark Ramzy shines a spotlight on three distinguished ... Resuscitation Read More REBEL CAST – IncrEMentuM26 Speaker Spotlight : George Willis and Mark Ramzy 🧭 REBEL Rundown 📝Introduction In this exciting episode of REBEL ... Endocrine, Metabolic, Fluid, and Electrolytes Read More Incrementum Conference 2026: Revolutionizing Emergency Medicine in Spain In this special episode of Rebel Cast, we spotlight the ... Read More The post REBEL CAST – IncrEMentuM26 Speaker Spotlight : Drs. Sara Crager and Ryan Ernst appeared first on REBEL EM - Emergency Medicine Blog.

🧭 REBEL Rundown 📌 Key Points 💪 Building Resilience: Rebel MIND, in partnership with Arena Labs, introduces a science-based performance coaching platform specifically tailored for healthcare professionals, focusing on stress management and burnout prevention.🤝 Personal Insights: Jackie Penn shares her journey from exercise science to digital coaching, highlighting the importance of tailored coaching in high-pressure environments like healthcare.🎯 Clinician-Centric Approach: Understanding unique challenges faced by ER doctors, the program provides practical tools for stress and transition management, improving both professional and personal life balance.💻 Revolutionary Wearables: Utilizing wearables, the program offers objective feedback on recovery and health metrics, allowing personalization of strategies to enhance clinician well-being. Click here for Direct Download of the Podcast. 📝 Introduction Welcome back to REBEL MIND, where MIND stands for Mastering Internal Negativity during Difficulty. Here we sharpen the person behind the practitioner by focusing on things that improve our performance, optimizing team dynamics and the human behavior that embodies the hidden curriculum of medicine. In this episode, we’re excited to continue collaboration with Arena Labs, where host Dr. Marco Propersi interviews Jackie Pen, Heading of Performance Coaching at Arena Labs. Arena Labs is helping us measure healthcare performance through innovative programs designed to combat burnout and enhance personal wellness using data-driven strategies.  🔙Previously Covered on REBEL MIND: Performance Under Pressure – What Medicine Can Learn from Elite Teams 🤔Cognitive Question How do specific performance coaching strategies and tools assist healthcare professionals, particularly those in emergency medicine, in managing stress and preventing burnout effectively? 💭 Why This is Important Burnout among healthcare workers is a growing concern, especially in such high-pressure environments as emergency and intensive care units. The collaboration with Arena Labs brings forth a vital focus on using data and coaching to build resilience among medical professionals. 🏥How This Applies to the Emergency Department or ICU? In the chaotic and high-stakes environment of the ED/ICU, healthcare professionals are often required to make split-second decisions under pressure while managing emotional stress. This necessitates not just clinical acumen but also strong emotional resilience and stress management skills. Performance coaching provides the tools and frameworks to enhance these skills, offering strategies like the de-stress breath and transition protocols to help clinicians navigate between high-pressure situations efficiently. These tools are designed to not only improve their professional performance but also ensure they are emotionally present for their personal lives, ensuring a healthier work-life balance. ⏩ Things You Can Do on Your Next Shift Practice the De-stress Breath: Before moving from one critical case to another, take a moment to take two inhales through the nose followed by an extended exhale, helping to reset your nervous system by activating your parasympathetic nervous system.Implement a Transition Protocol: Choose a point in your journey home to mentally switch from clinician to family member, helping you to be more present outside of work.Optimize Your Nutrition and Rest: Even small changes during your shift, like meals that promote easy digestion or quick physical activities, can make a significant difference in your energy levels.Engage with Wearables: If possible, use wearables to monitor your physiological responses, helping tailor personalized strategies for your shifts 👀 Where to Learn More Intrigued by the possibilities this partnership offers? You can explore more by visiting Arena Labs’ website here. Also, check out the comprehensive coaching program available, designed specifically for healthcare providers looking to enhance their well-being and performance. 🚨 Clinical Bottom Line In an era where burnout is pervasive, our collaboration with Arena Labs offers a beacon of hope for healthcare workers. By leveraging cutting-edge data insights and practical coaching, this partnership aims to redefine healthcare wellness, fostering a sustainable, resilient workforce that’s equipped to navigate the pressures of modern medicine. Join us in this journey towards enhanced well-being and workforce empowerment, ensuring that those who care for us are also cared for. Meet the Authors Marco Propersi Co-Editor-in-Chief Vassar Brothers Medical Center, Poughkeepsie, NY Jackie Pen Head of Performance Coaching Arena Labs The post REBEL MIND: The Power of Performance Coaching in Medicine appeared first on REBEL EM - Emergency Medicine Blog.

🧭 REBEL Rundown 📌 Key Points 🎯Partnership Focus: New collaboration with Arena Labs aimed at enhancing healthcare worker wellness.🏃🏽‍️‍➡️Personalized Coaching: Tools and coaching programs designed for stress management and performance improvement.📊Data-Driven Insights: Utilizing wearable sensor data to tackle burnout effectively.🌄Broad Impact: Offers a unique opportunity to contribute to large-scale healthcare improvements. Click here for Direct Download of the Podcast. 📝 Introduction Welcome back to REBEL MIND, where MIND stands for Mastering Internal Negativity during Difficulty. Here we sharpen the person behind the practitioner by focusing on things that improve our performance, optimizing team dynamics and the human behavior that embodies the hidden curriculum of medicine. In this episode, hosted by Drs. Mark Ramzy and Marco Propersi, we’re excited to introduce a collaboration with Arena Labs. Arena Labs is helping us measure healthcare performance through innovative programs designed to combat burnout and enhance personal wellness using data-driven strategies.  Cognitive Question What would it look like in emergency medicine and critical care to be set up with the same tools as elite teams and professional athletes when it comes to measuring performance and recovery? How would our patients benefit? 💭 Why This is Important Burnout among healthcare workers is a growing concern, especially in such high-pressure environments as emergency and intensive care units. The collaboration with Arena Labs brings forth a vital focus on using data and coaching to build resilience among medical professionals. 🌟Be Brilliant at the Basics Ask yourself — “What is it on your time off that gives you a deep sense of fulfillment?”On your time off are you doing things that fill your bucket and add to your recovery? What is Allostasis and Allostatic Load Allostasis: Our body’s ability to adapt over time to stress. It’s relevant to the phase you are in during this particular season in your life. Ex. You are a first year medical student freaking out about your very first exam. Over time as you do more exams, they are still stressful, but by now you have developed modified study habits to succeed and get used to the frequent examsIn the context of emergency medicine, you may be nervous or stressed about your first shift at a new hospital but overtime you learn the staff, the location of equipment, the acuity of that particular site, the patient population so over time you get used to the stress of a shift at that new hospitalAllostatic Load: The wear and tear on the body from chronic stress due to maladaptation or poor recovery methods.This refers to the cumulative burden of chronic stress and life events. It involves the interaction of different physiological systems at varying degrees of activity.Ex. You are an emergency medicine physician at a very busy, high acuity center and have never prioritized taking care of yourself on/during a shift. As a result, external factors add to not being able to fully recover when you get home or are off shift (ie. Admin work, teaching obligations, family/friends) and so you never fully recover before you have to go back on shift to the same stressors you just exposed yourself to. So the cycle continuesFigure 1: Long term effects of Chronic Stress (Source: Andrew Hogue from NeuroFit) 🏥How This Applies to the Emergency Department or ICU? Healthcare workers in emergency departments (ED) and intensive care units (ICU) are often under enormous stress due to the nature of their work. Arena Labs’ program offers tailored solutions, helping ED and ICU staff manage their unique challenges through effective recovery techniques and performance tools. This approach caters specifically to the demanding schedules and the unpredictability inherent in these environments. 👀 Where to Learn More Intrigued by the possibilities this partnership offers? You can explore more by visiting Arena Labs’ website here. Also, check out the comprehensive coaching program available, designed specifically for healthcare providers looking to enhance their well-being and performance. 🚨 Clinical Bottom Line In an era where burnout is pervasive, our collaboration with Arena Labs offers a beacon of hope for healthcare workers. By leveraging cutting-edge data insights and practical coaching, this partnership aims to redefine healthcare wellness, fostering a sustainable, resilient workforce that’s equipped to navigate the pressures of modern medicine. Join us in this journey towards enhanced well-being and workforce empowerment, ensuring that those who care for us are also cared for. 📚References Guidi J, et al.Allostatic Load and Its Impact on Health: A Systematic Review. Psychother Psychosom. 2021; Epub 2020 Aug 14. PMID: 32799204Frueh BC, et al.“Operator syndrome”: A unique constellation of medical and behavioral health-care needs of military special operation forces. Int J Psychiatry Med. Epub 2020 Feb 13. PMID: 32052666 Meet the Authors Mark Ramzy, DO Co-Editor-in-Chief Cardiothoracic Intensivist and EM Attending RWJBH / Rutgers Health, Newark, NJ Marco Propersi Co-Editor-in-Chief Chair of Emergency Medicine at Vassar Brothers Medical Center, Poughkeepsie, NY Brain Ferguson Founder and CEO Arena Labs The post REBEL MIND: Performance Under Pressure – What Medicine Can Learn from Elite Teams appeared first on REBEL EM - Emergency Medicine Blog.

🧭 REBEL Rundown 🗝️ Key Points 💨 NIV = Support without a tube: CPAP, BiPAP, and HFNC improve oxygenation and reduce the work of breathing.🫁 CPAP = Continuous pressure: Best for hypoxemic patients (e.g., pulmonary edema, OSA).️ BiPAP = Two pressures (IPAP/EPAP): Great for hypercapnic failure (e.g., COPD, obesity hypoventilation).🌬️ HFNC = Heated, humidified high flow: Reduces effort, improves comfort, and enhances oxygen delivery.🩺 Supportive, not definitive: NIV stabilizes patients while the underlying cause is treated. Click here for Direct Download of the Podcast. 📝 Introduction Non-invasive ventilation (NIV) refers to respiratory support provided without endotracheal intubation. The most common modalities include continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP), and high-flow nasal cannula (HFNC). These therapies aim to improve oxygenation, reduce the work of breathing, and potentially prevent invasive mechanical ventilation. 💨 CPAP and BiPAP CPAP delivers a single, continuous pressure during inspiration and expiration. This pressure (commonly 5–10 cm H₂O) helps recruit atelectatic alveoli, reduce shunt, and improve oxygenation. It is commonly used for conditions like pulmonary edema, obstructive sleep apnea, or mild hypoxemia without significant ventilatory failure.BiPAP alternates between two pressures:Inspiratory positive airway pressure (IPAP), augments tidal volume and unloads inspiratory muscles.Expiratory positive airway pressure (EPAP), maintains alveolar recruitment and improves oxygenation.The differential between IPAP and EPAP is critical for reducing hypercapnia in patients with COPD exacerbations or acute hypercapnic respiratory failure.IndicationsCPAP: hypoxemia without major ventilatory failure (e.g., cardiogenic pulmonary edema, atelectasis, OSA).BiPAP: hypercapnia with increased work of breathing (e.g., COPD exacerbation, neuromuscular weakness, obesity hypoventilation).A helpful way to conceptualize CPAP and BiPAP is through the hairdryer analogy. Imagine placing a hairdryer in your mouth: 🩺 Clinical Considerations Masks can be uncomfortable, impair secretion clearance, and limit oral intake.Some patients require sedation to tolerate NIV, but this carries risks in patients with unprotected airways.NIV is thus a high-stakes intervention requiring close monitoring.Common starting dose to understand titration, but start at the level appropriate for your patient:  IPAP 10 cm H₂O / EPAP 5 cm H₂O (“10/5”) and are titrated:Increase IPAP to improve tidal volume and CO₂ clearance.Increase EPAP to recruit alveoli and improve oxygenation.Both may be raised simultaneously if the patient is both hypoxemic and hypercapnic. 🚀 High-Flow Nasal Cannula (HFNC) H: Heated & humidified – improves mucociliary clearance, prevents airway drying, and enhances tolerance. I: Inspiratory flow – high flow meets or exceeds patient demand, reducing respiratory rate and effort.F: Functional residual capacity – modest generation of positive end-expiratory pressure (PEEP), promoting alveolar recruitment.L: Lighter – generally more comfortable and less restrictive than mask-based NIV.O: Oxygen dilution – minimizes entrainment of room air, delivering higher and more predictable FiO₂.W: Washout – flushes anatomical dead space, reducing CO₂ rebreathing.HFNC delivers heated, humidified oxygen at high flow rates (30–60 L/min) through wide-bore nasal prongs. A mnemonic, H-I-F-L-O-W, helps summarize its mechanisms:Indications: Traditionally used for acute hypoxemic respiratory failure (e.g., pneumonia), HFNC is increasingly studied for hypercapnic failure as well, with trials suggesting non-inferiority to BiPAP in select populations. Post Peer Reviewed By: Marco Propersi, DO (Twitter/X: @Marco_propersi), and Mark Ramzy, DO (X: @MRamzyDO) 👤 Show Notes Syed Moosi Raza, MD PGY 3 Internal Medicine Resident Cape Fear Valley Internal Medicine Residency Program Fayetteville NC Aspiring Pulmonary Critical Care Fellow 🔎 Your Deep-Dive Starts Here REBEL Core Cast – Pediatric Respiratory Emergencies: Beyond Viral Season Welcome to the Rebel Core Content Blog, where we delve ... Pediatrics Read More REBEL Core Cast 143.0–Ventilators Part 3: Oxygenation & Ventilation — Mastering the Balance on the Ventilator When you take the airway, you take the wheel and ... Thoracic and Respiratory Read More REBEL Core Cast 142.0–Ventilators Part 2: Simplifying Mechanical Ventilation – Most Common Ventilator Modes Mechanical ventilation can feel overwhelming, especially when faced with a ... Thoracic and Respiratory Read More REBEL Core Cast 141.0–Ventilators Part 1: Simplifying Mechanical Ventilation — Types of Breathes For many medical residents, the ICU can feel like stepping ... Thoracic and Respiratory Read More REBEL Core Cast 140.0: The Power and Limitations of Intraosseous Lines in Emergency Medicine The sicker the patient, the more likely an IO line ... Procedures and Skills Read More REBEL Core Cast 139.0: Pneumothorax Decompression On this episode of the Rebel Core Cast, Swami takes ... Procedures and Skills Read More The post REBEL Core Cast 148.0–Demystifying Non-Invasive Ventilation & HiFlow appeared first on REBEL EM - Emergency Medicine Blog.

🧭 REBEL Rundown 📌 Key Points 🧠 We don’t know what we don’t know: Low experience can inflate confidence; true expertise usually brings humble certainty.🏥 ED relevance is universal: From central lines to transvenous pacing, over- or under-confidence shows up at every level—intern to seasoned attending.🧩 Metacognition matters: Accurate self-assessment is a clinical skill; reflection + feedback loops keep us calibrated.🛠️ Practice beats bravado: Skill decay is real; deliberate practice and HALO (high-acuity, low-occurrence) refreshers protect patients.🤝 Psychological safety ≠ niceties: “Confident humility” enables questions, feedback, and better resuscitation decisions—especially under uncertainty. Click here for Direct Download of the Podcast. 📝 Introduction Welcome to REBEL MIND—Mastering Internal Negativity during Difficulty. In this series, we turn the same critical lens REBEL EM uses for literature inward—into mindset, leadership, and psychological safety—so we can deliver better care outward to patients and teams.In this episode and blog post, hosts Mark Ramzy and Kim Bambach (Assistant Professor of Emergency Medicine, The Ohio State University) explore a deceptively simple question: How accurately can we assess our own performance? The answer hinges on a classic cognitive bias that touches all of us in emergency medicine. 🧾 Paper Kruger J, Dunning D. Unskilled and unaware of it: how difficulties in recognizing one’s own incompetence lead to inflated self-assessments. J Pers Soc Psychol. 1999 Dec;7 PMID: 10626367 Cognitive Question How accurately can we assess our own performance? 💭 What is the Dunning-Kruger Effect? The Dunning–Kruger Effect is a cognitive bias where:Lower-skill individuals tend to overestimate their competence, andHigher-skill individuals often underestimate theirs.Translation for the busy clinician: early on the learning curve, confidence spikes (“Mount Stupid”) because we don’t yet see the complexity. As experience accrues, confidence dips (“Valley of Despair”) with growing awareness, then rises again—grounded in nuance and humility.Key insight: True expertise ≠ louder certainty; it’s often quieter, more curious, and more collaborative. How It Applies to the Emergency Department Procedures (e.g., central lines, TVP): Watching a 5-minute video creates “I got this” energy—until the wire won’t pass, the patient thrashes, or you hit carotid. Competence includes troubleshooting in context.Skill Decay is Inevitable: If you haven’t done a chest tube or a TVP in months, you’re not as sharp as last time. Without deliberate refreshers, you drift below the safe-performance line.Everyone’s a Novice Somewhere: New disease entities, evolving algorithms, new tools (POCUS, decision support) mean even attendings routinely re-enter novice zones.Feedback Blind Spots: Lower performers can both overestimate their skills and resist feedback—while many high performers (particularly women, per discussed literature) undervalue their abilities.Culture is Clinical: The ED demands decisive action amid uncertainty. Psychological safety + confident humility lets teams surface alternative diagnoses, challenge momentum, and correct course fast. ⏩Immediate Action Steps for Your Next Shift Run a 60-second debrief on two casesWhat went well? What would I do differently next time? Write one improvement you’ll test today.Play “What if the opposite were true?”Anchored on “lumbosacral strain”, Ask, What if fever/incontinence appears? How does that change my path?Solicit 360° micro-feedbackAsk a nurse, resident, and peer: “One thing I did well; one thing to improve.” Say “thank you,” not “but.”Schedule a HALO refresher this weekPick one high-acuity, low-occurrence procedure (TVP, cric, thoracotomy). Do a 10-minute mental model + equipment walk-through; book sim time if available.Adopt a pre-procedure pauseIf X goes wrong, I’ll do Y. Name two likely failure modes (e.g., “wire won’t advance,” “delirium/agitation”) and your first corrective step.Language shift on shiftSwap “I’m sure” → “I’m reasonably confident, here’s my plan B.” Invite input: “What am I missing?” Conclusion The Dunning–Kruger Effect isn’t a moral failing; it’s a predictable human pattern that every clinician rides—often multiple times per day in the ED. The antidote is metacognition: routine reflection, explicit debiasing, deliberate practice, and feedback within a psychologically safe culture. 🚨 Clinical Bottom Line Competence is quiet and curious. The more we know, the more we recognize what we don’t—and the better we become at caring for patients and each other. Further Reading Dunning D, Kruger J. Unskilled and Unaware of It (1999). Classic paper introducing the effect.Croskerry P. Cognitive forcing strategies in clinical decision-making.Kahneman D. Thinking, Fast and Slow. Heuristics & biases in high-stakes decisions.Ericsson KA. Peak: Secrets from the New Science of Expertise. Deliberate practice & skill acquisition.Edmondson AC. The Fearless Organization. Psychological safety and learning culture in teams. Meet the Authors Mark Ramzy, DO Co-Editor-in-Chief Cardiothoracic Intensivist and EM Attending RWJBH / Rutgers Health, Newark, NJ Kim Bambach, MD Podcasting Manager Assistant Professor of Emergency Medicine Ohio State University The post REBEL MIND – The Dunning Kruger Effect: Why Looking Inward Improves Patient Care appeared first on REBEL EM - Emergency Medicine Blog.

🧭 REBEL Rundown 🗝️ Key Points 💨 Peak vs. Plateau Pressures: PIP reflects total airway resistance and compliance, while Pplat isolates alveolar compliance—elevations in both suggest decreased lung compliance (e.g., ARDS, pulmonary edema, pneumothorax).🧱 PEEP Protects Alveoli: Maintains alveolar recruitment and prevents collapse; typical range 5–8 cmH₂O, but higher levels may benefit moderate–severe ARDS.️ Driving Pressure (ΔP = Pplat − PEEP): Lower ΔP reduces atelectrauma and improves outcomes; optimize by adjusting PEEP thoughtfully.💥 Prevent VILI: Keep Pplat < 30 cmH₂O, use low tidal volumes (6 mL/kg IBW), and monitor for barotrauma, volutrauma, atelectrauma, and biotrauma.📚 Evidence-Based Practice: ARDSNet and subsequent trials confirm that lung-protective ventilation—low Vt, limited pressures, and individualized PEEP—improves survival in ARDS. Click here for Direct Download of the Podcast. 📝 Introduction This episode reviews essential ventilator pressures and how to interpret them during ICU rounds. 🚀 Under Pressure Peak Inspiratory Pressure (PIP)Definition: Total pressure required to deliver a breath.Reflects: Airway resistance + lung/chest wall compliance.Common Causes of ↑ PIP:Mucus pluggingBiting the endotracheal tubeKinked tubing or bronchospasmPlateau Pressure (Pplat)Definition: Alveolar pressure measured after an inspiratory hold.Reflects: Lung compliance (stiffness of lung tissue).When Both PIP & Pplat Are Elevated:→ Indicates poor compliance (e.g., ARDS, pulmonary edema, pneumothorax).Positive End-Expiratory Pressure (PEEP)Definition: Pressure remaining in airways at end-expiration to prevent alveolar collapse.Typical Range: 5–8 cmH₂O but needs to titrated to meet patient requirements Notes:Provides physiologic “glottic” PEEP in intubated patients.Using high PEEP strategy shows mortality benefit only in moderate–severe ARDS in meta-analysis.Driving Pressure (ΔP)Definition: ΔP = Pplat − PEEP.Reflects: Pressure needed to keep alveoli open during the respiratory cycle.Goal: Lower ΔP → less atelectrauma & improved outcomes.Optimize: Increase PEEP to reduce ΔP and alveolar cycling. 📖 Interpreting High PIP/High Pplat ↑ PIP & ↑ PplatInterpretation: ↓ ComplianceCommon Causes: ARDS, pulmonary edema, pleural effusion, pneumothorax↑ PIP & Normal/Low PplatInterpretation: ↑ Airway ResistanceCommon Causes: Mucus plug, bronchospasm, tube obstruction or biting 🤕 Ventilator-Associated Lung Injury (VILI) Barotrauma:Mechanism: Excessive airway pressure damages alveoli.Prevention: Keep Pplat < 30 cmH₂O.Volutrauma:Mechanism: Overdistension from excessive tidal volumes.Prevention: Use low tidal volume ventilation (6 mL/kg ideal body weight).ARDSNet trial: 6 mL/kg → lower mortality compared to 12 mL/kg.Ideal Body Weight: Based on height and sex, not actual weight.Typical patient: Tidal Volume: 6–8 mL/kg IBWARDS: Tidal Volume: 4–6 mL/kg IBWAtelectrauma:Mechanism: Repeated opening/collapse of unstable alveoli.Prevention: Optimize PEEP to keep alveoli open and reduce driving pressure.Biotrauma:Mechanism: Inflammatory cascade (↑ IL-6, TNF-α) from mechanical injury.Effect: Can trigger systemic inflammation & multiorgan dysfunction.Prevention: Minimize all other forms of VILI. Post Peer Reviewed By: Marco Propersi, DO (Twitter/X: @Marco_propersi), and Mark Ramzy, DO (X: @MRamzyDO) 👤 Show Notes Joel Rios Rodriguez, MD PGY 3 Internal Medicine Resident Cape Fear Valley Internal Medicine Residency Program Fayetteville NC Aspiring Pulmonary Critical Care Fellow 🔎 Your Deep-Dive Starts Here REBEL Core Cast 137.0: A Simple Approach to Sinus Tachycardia Sinus tachycardia is the most prevalent cardiac dysrhythmia in critically ... Cardiovascular Read More REBEL Core Cast 136.0: A Simple Approach to the Tachypneic Patient In this episode, we focus on the bedside evaluation of ... Thoracic and Respiratory Read More REBEL Core Cast 135.0: A Simple Approach to Hypoxemia (vs. Hypoxia) In this episode, we break down a practical bedside approach ... Resuscitation Read More REBEL Core Cast 1.0 – The Intro REBEL EM-ers: Salim, Jenny and I would like to announce ... Read More The post REBEL Core Cast 147.0–Ventilators Part 5: Key Mechanical Ventilator Pressures & Definitions Made Simple appeared first on REBEL EM - Emergency Medicine Blog.

🧭 REBEL Rundown 🗝️ Key Points ❌ Don’t chase perfect numbers: Adequate and safe is often better than “perfect but harmful.”💨 Oxygenation levers: Start with FiO₂ and PEEP, but remember MAP is the true driver.🫁 Ventilation levers: Adjust RR and TV, tailored to underlying physiology.🚫 Watch your obstructive patients: Sometimes less RR is more. Click here for Direct Download of the Podcast. 📝 Introduction Ventilator management can feel overwhelming—there are so many knobs to turn, numbers to watch, and changes to make. But before adjusting any settings, it’s crucial to understand why the patient is in distress in the first place, because the right strategy depends on the underlying cause. In this episode, we’ll walk through three different cases to see how the approach changes depending on the problem at hand. ️ The 4 Main Ventilator Settings  Tidal Volume (Vt) 🌬️ Amount of air delivered with each breath Typically set based on ideal body weight (6–8 mL/kg for lung protection) Respiratory Rate (RR) ⏱️ Number of breaths delivered per minute Adjusted to control minute ventilation and manage CO₂  FiO₂ (Fraction of Inspired Oxygen) ⛽ Percentage of oxygen delivered Adjusted to maintain adequate oxygenation (goal SpO₂ 92–96%, PaO₂ 55–80 mmHg). PEEP (Positive End-Expiratory Pressure) 🎈 Pressure maintained in the lungs at the end of exhalation to prevent alveolar collapse and improve oxygenation 🧮 Modes of Ventilation AC/VC (Assist Control – Volume Control)How it Works: Delivers a set tidal volume with each breath (whether patient- or machine-triggered).When It’s Used / Pros: Most common initial mode; guarantees minute ventilation; good for patients with variable effort.Limitations / Cons: May cause patient–ventilator dyssynchrony if set volumes don’t match patient’s demand.AC/PC (Assist Control – Pressure Control)How it Works: Delivers a set inspiratory pressure for each breath; tidal volume varies depending on lung compliance/resistance.When It’s Used / Pros: Useful in ARDS (lung-protective strategy), limits peak airway pressures.Limitations / Cons: Tidal volume not guaranteed; must closely monitor volumes and minute ventilation.PRVC (Pressure-Regulated Volume Control)How it Works: Hybrid: set target tidal volume, ventilator adjusts inspiratory pressure breath-to-breath to achieve it (within limits).When It’s Used / Pros: Common default mode on newer vents; combines benefits of VC (guaranteed volume) + PC (pressure limitation).Limitations / Cons: Can increase pressures if compliance worsens.SIMV (Synchronized Intermittent Mandatory Ventilation)How it Works: Delivers set breaths, but allows spontaneous patient breaths in between (without guaranteed volume).When It’s Used / Pros: Used for weaning; allows patient effort.Limitations / Cons: Risk of increased work of breathing if spontaneous breaths are inadequate.PSV (Pressure Support Ventilation)How it Works: Every breath is patient-initiated; ventilator provides preset pressure support to overcome airway resistance.When It’s Used / Pros: Weaning trials; patients with intact drive who just need assistance.Limitations / Cons: Not a full-support mode; not for unstable patients without spontaneous drive. ♟️ Ventilation Strategies Airway ProtectionLow GCS, seizure, strokeLoss of gag/cough reflexHigh aspiration risk (vomiting, GI bleed, poor mental status)Hypoxemic Respiratory FailureSevere pneumoniaARDSPulmonary edemaInhalation injuryVentilatory (Hypercapnic) Failure / Increased Ventilation DemandSevere metabolic acidosis (DKA, sepsis, renal failure) → need high minute ventilationCOPD, asthma (if decompensating)Neuromuscular weakness (myasthenia, Guillain–Barré, spinal cord injury)Airway Obstruction / Anticipated Loss of AirwayTumor, anaphylaxis, angioedemaFacial or airway traumaPre-op / anticipated deterioration Post Peer Reviewed By: Marco Propersi, DO (Twitter/X: @Marco_propersi), and Mark Ramzy, DO (X: @MRamzyDO) 👤 Show Notes Priyanka Ramesh, MD PGY 1 Internal Medicine Resident Cape Fear Valley Internal Medicine Residency Program Fayetteville NC Aspiring Pulmonary Critical Care Fellow 🔎 Your Deep-Dive Starts Here It seems we can't find what you're looking for. The post REBEL Core Cast 146.0–Ventilators Part 4: Setting up the Ventilator appeared first on REBEL EM - Emergency Medicine Blog.

🧭 REBEL Rundown 📝 Introduction Welcome to the Rebel Core Content Blog, where we delve into crucial knowledge for emergency medicine. Today, we share insightful tips from PEM specialist Dr. Elise Perelman, shedding light on respiratory challenges in infants, toddlers, and young children during the viral season. Understanding that most cases involve typical viruses, we aim to equip you with diagnostic pearls to identify more serious pathologies. Click here for Direct Download of the Podcast. 🔍 Recognizing Respiratory Patterns Pearl #1: Look at Your PatientBegin exams from the doorway. Observing patterns such as accessory muscle usage can reveal a patient’s respiratory effort. Specify whether the work of breathing occurs during inspiration, expiration, or both. Inspiratory work indicates difficulty getting air in, while expiratory work suggests trouble pushing air out. Silent tachypnea may point to other issues, like acidemia or pneumothorax. 🩺 Localizing Sounds for Accurate Diagnosis Pearl #2: Localize the SoundBreathing noises signal varied respiratory issues. Stridor, often heard on inspiration, results from obstructions above the thoracic inlet. Conversely, wheezing, generally linked to exhalation, indicates obstructions in the lower airways. Watch for signs like ‘silent chest’—a dangerous, severe obstruction, and distinguish grunting as a bodily mechanism to prevent alveolar collapse. Correctly identifying the sound assists in determining the appropriate intervention. 💉 Tailoring Treatment for Effective Results Once a sound is localized, treatments vary. We explore Soder from nasal congestion, typically needing supportive care and suctioning. Stridor from conditions like croup is eased with interventions to reduce airway swelling, such as steroids or inhaled epinephrine. Conversely, wheezing in infants is often due to bronchiolitis—not bronchospasms—and over-treatment is to be avoided. Supportive measures including suction, hydration, and oxygen are preferred unless improvement warrants bronchodilators. 🌬️ Intervening with Severe Asthma In severe cases of asthma or bronchiolitis, where standard at-home treatments fail, immediate adjunct therapies like intramuscular epinephrine become essential. Administering this quickly can alleviate obstruction when inhalants aren’t effective due to low air movement. 🦓 Navigating the Zebras of Respiratory Cases When recognizing Zebras—uncommon cases overshadowed by routine diagnoses—remain vigilant for histories or presentations that don’t conform. Conditions like pneumonia, bacterial tracheitis, and even myocarditis may mimic more common issues. 📌 Conclusion As attending physicians, our role extends beyond conventional treatment—it’s about discerning the atypical from the typical. Dr. Perelman urges continual reassessment, emphasizing reliance on observational skills as much as technological aid. Keeping keen on respiratory nuances ensures we catch those outlier cases, paving the way for adept medical care despite the overwhelming prevalence of viral infections.Stay tuned for more pearls and insights in our future posts, as Dr. Perelman shares further strategies for effective pediatric emergency care. For more resources, continue exploring our faculty’s valuable contributions on our site. Until then, stay safe and perceptive in your practice. Post Peer Reviewed By: Mark Ramzy, DO (X: @MRamzyDO), and Marco Propersi, DO (X: @Marco_Propersi) 👤 Guest Elise Perlman MD Pediatric Emergency Medicine​ Assistant Professor, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Meet The Team 🔎 Your Deep-Dive Starts Here REBEL MIND: The Power of Performance Coaching in Medicine In this episode, we're excited to continue collaboration with Arena ... Human Behavior Read More REBEL MIND: Performance Under Pressure – What Medicine Can Learn from Elite Teams Welcome back to Rebel MIND, the podcast where we sharpen ... Human Behavior Read More REBEL Core Cast 148.0–Demystifying Non-Invasive Ventilation & HiFlow Non-invasive ventilation (NIV) refers to respiratory support provided without endotracheal ... Thoracic and Respiratory Read More REBEL MIND – The Dunning Kruger Effect: Why Looking Inward Improves Patient Care In this episode and blog post, hosts Mark Ramzy and ... Human Behavior Read More REBEL Core Cast 147.0–Ventilators Part 5: Key Mechanical Ventilator Pressures & Definitions Made Simple This episode reviews essential ventilator pressures and how to interpret ... Thoracic and Respiratory Read More REBEL Core Cast 146.0–Ventilators Part 4: Setting up the Ventilator Ventilator management can feel overwhelming—there are so many knobs to ... Thoracic and Respiratory Read More The post REBEL Core Cast – Pediatric Respiratory Emergencies: Beyond Viral Season appeared first on REBEL EM - Emergency Medicine Blog.

🧭 REBEL Rundown 📝Introduction Welcome to this special edition of the REBEL Cast, where we unravel key highlights and educational insights from the IncrEMentuM Conference in Spain. This event is a cornerstone for advancing emergency medicine education, drawing esteemed speakers and participants from around the globe. As emergency medicine gains traction in Spain, this conference has become an essential platform for knowledge exchange and professional growth. Today, host Dr. Mark Ramzy shines a spotlight on three distinguished speakers: Dr. Jess Mason, Dr. Tarlan Hedayati, and Dr. Simon Carley, who shared their expertise and experiences at this transformative gathering last spring. Click here for Direct Download of the Podcast. 🤔What's IncrEMentuM? A new conference and a pivotal gathering for emergency medicine professionals worldwide, has become an essential platform for education, collaboration, and advocacy, especially in light of emergency medicine’s recent recognition as a specialty in Spain. The conference is praised for its outstanding production quality, engaging speakers, and its capacity to foster a global community of emergency care professionals. 🦪Pearls from Their IncrEMentuM 2025 Lectures Think about alternative diagnoses that could be driving the patient’s atrial fibrillationMaybe the atrial fibrillation is an adaptive response and slowing them down (whether chemically or electrically) may cause more harm than goodGet in the mental space before having to perform a High Acuity Low Occurrence (HALO) procedure and walk through each of the parts step by stepEMRAP has uploaded the video of the Resuscitative Hysterotomy here (Subscription required to watch)Like many things in critical care, a patient with a severe head injury requires you to do many little things very well (ie. reducing ICP increases by taking off the C-collar if able, positioning the patient appropriately, knowing when to use certain medications) See you in Spain! The upcoming conference aims to gather world-class educators once more and promises an enriching experience for all attendees. Drs. Tarlan Hedayati, Jess Mason and Simon Carley, along with many others, will be there at the event. For more information on the IncrEMentuM Conference and to register, visit their website! See you there! Tarlan Hedayati, MD Vice Chair of Education and Associate Program Director Cook County, Chicago, IL Jess Mason, MD Associate Professor of Emergency Medicine Vanderbilt University, Nashville, TN Simon Carley, MD, PhD Professor of Emergency and Dean of the Royal College of Emergency Medicine Manchester, England 🔎 Your Deep-Dive Starts Here REBEL Core Cast 110.0 – On Shift Learning Pearls Take Home Points: Patients with recent onset atrial fibrillation can ... Read More The post REBEL CAST – IncrEMentuM26 Speaker Spotlight : Drs. Tarlan Hedayati, Jess Mason and Simon Carley appeared first on REBEL EM - Emergency Medicine Blog.

🧭 REBEL Rundown 📌 Key Points 🫀 Prolonged QTc raises risk of torsades de pointes ⏱️ Correct for heart rate: QTc > 440 ms (men) or > 460 ms (women); > 500 ms = high TdP risk.💊 Common culprits: Methadone, ondansetron, macrolides, fluoroquinolones, antipsychotics.🧪 Prevention: Check & replete K, Mg, Ca and avoid QT-prolonging meds when possible.🚑 If TdP develops: Defibrillate + IV magnesium and stop offending agents. Click here for Direct Download of the Podcast. 📝 Introduction The QT interval is a vital part of ECG interpretation, reflecting the heart’s electrical recovery after each beat. When prolonged, it can set the stage for torsades de pointes. Understanding how to measure and correct the QT interval, identify high-risk medications, and act quickly when TdP occurs is essential for every clinician. This guide walks you through the physiology, interpretation, common causes, and emergency management of QTc prolongation to keep your patients safe. 🤔 Definition and Physiology QT evaluation is a fundamental component of EKG analysis. The QT interval reflects the time from ventricular depolarization and contraction through ventricular repolarization and relaxation.Clinically, QT prolongation increases the risk of torsades de pointes (TdP) – a form of polymorphic ventricular tachycardia (a non-perfusing rhythm) that is classically described as a pattern of “twisting points” or alternating amplitudes. This occurs when a premature ventricular contraction leads to an R on T phenomenon during the repolarization period.The differential for QT prolongation is long and varied: congenital long QT, electrolyte disturbances (hypoK, hypoMg, hypoCa), hypothermia, myocardial ischemia, and increased intracranial pressure. Moreover, a whole host of xenobiotics can prolong the QT interval: methadone, anti-microbials, anti-emetics, anti-psychotics, and anti-dysrhythmics. 🧮 ECG Interpretation The QT interval must be interpreted in conjunction with the patient’s heart rate. The QT interval with shorten in the context tachycardia and length in the context of bradycardia. In other words, tachycardia is protective when evaluating the patient with prolonged QT.With that in mind, many EKG machines will calculate a corrected QT interval or QTc. The QTc is a standardized way to account for variations in heart rate so clinicians are able to compared QT intervals at different heart rates over time and thus calculate risk.Generally, a QTc is considered prolonged if greater than 440ms in males or 460ms in females. Once the QTc > 500msec, the risk of TdP increases 2-3 fold.1A variety of different correction formulas exist: Bazett, Fridericia, Hodges, Framingham, Rautaharju.Manually, the QT interval should be measured from the beginning of the QRS complex to the end of the T wave – and thus should be measured in leads where all portions can be visualized, most frequently lead II or V5/V6. Ideally, the QT interval should be average over 3 or more beats.2 To determine the end of the T wave, a tangent line should be drawn through the maximum slope of the T wave – the point at which this line crosses the isoelectric line is the end of the T wave.3 💊 Commonly Used QTc Prolonging Medications Methadone: particularly concerning because not only does it inherently prolong QT but also induces a bradycardiaAntiemetics: OndansetronMacrolides: azithromycin, erythromycin, clarithromycinFluroquinolones: ciprofloxacin, levofloxacinAntipsychotics: Haloperidol, Olanzapine ️ Management Prevention is key!Assess electrolytes (Mg, Ca, K) and replete as neededTelemetry MonitoringIf patient happens to fall into TdP, initiate ACLS with immediate defibrillation and magnesium.Withdrawal of offending agents. 📚 References Drew BJ, Ackerman MJ, Funk M, Gibler WB, Kligfield P, Menon V, Philippides GJ, Roden DM, Zareba W. Prevention of torsade de pointes in hospital settings: a scientific statement from the American Heart Association and the American College of Cardiology Foundation. Circulation. 2010 Mar;121(8):1047-1060.Postema PG and Wilde AAM. The measurement of the QT interval. Curr Cardiol Rev. 2014 Aug;10(3): 287-294.https://litfl.com/qt-interval-ecg-library/ Post Peer Reviewed By: Marco Propersi, DO (Twitter/X: @Marco_propersi), and Mark Ramzy, DO (X: @MRamzyDO) 👤 Associate Editor Anand Swaminathan MD, MPH All Things REBEL EM Meet The Team 🔎 Your Deep-Dive Starts Here REBEL Core Cast 134.0 – Acetaminophen Toxicity Acetaminophen (APAP) overdose remains one of the most common causes ... Toxicology Read More Street Medicine: Compassionate Care for the Unhoused Introduction: In this episode of Rebel Cast, host Marco Propersi, ... Read More REBEL Cast Ep91: Static Ultrasound vs Landmark Placement of Subclavian Central Lines Background Information: Central venous catheterization is a common procedure performed in ... Procedures and Skills Read More REBEL Cast Ep82: Timing of Endoscopy for UGIB Background: Upper endoscopy allows for the identification of the source ... Abdominal and Gastroinstestinal Read More REBEL Cast Ep 46b: Vent Management in the Crashing Patient with Haney Mallemat In Episode 46a we discussed respiratory failure and NIV.  In ... Thoracic and Respiratory Read More REBEL Cast Ep 46a – Respiratory Failure and NIV with Haney Mallemat Imagine you have a patient in respiratory failure sitting right ... Thoracic and Respiratory Read More The post REBEL Core Cast 145.0: Understanding QTc Prolongation: Causes, Risks, and Management appeared first on REBEL EM - Emergency Medicine Blog.