🧭 REBEL Rundown

📌 Key Points

The 4 Steps of an ED Consult:

1. 👋 Introduce yourself and your role
2. 🎯 Lead with the outcome (the ask)
3. 🧾 Give a focused case summary (why it’s theirs + what you’ve done)
4. 🔁 Close the loop (timeline, next steps, contingencies)

Click here for Direct Download of the Podcast.

📝 Introduction

Today we’re tackling one of the most important (and most under-taught) skills in emergency medicine: how to call a consult in the ED and what to do when a consultant pushes back.

To call a consult in the ED, start with a brief introduction, lead with the outcome you need (“the ask”), give a focused decision-relevant summary, and close the loop with timeline and next steps. If the consultant resists, clarify the “why,” restate the ask, offer alternatives, and escalate when patient safety or disposition is at risk.

After two decades in emergency medicine and countless consult calls, here’s a simple framework—plus copy/paste scripts—to make your consults faster, clearer, and easier to say “yes” to.

🤔 Why Consult Skills Matter in Emergency Medicine

• Consults aren’t a formality—they’re a patient-care intervention. Strong consult communication:
  • Reduces delays in time-sensitive care
  • Improves ED throughput and disposition
  • Decreases conflict and miscommunication
  • Clarifies ownership and next steps
  • Protects the patient (and the team) when plans are unclear

🪜 The 4-Step ED Consult Framework (Introduction → Ask → Summary → Close the Loop)

Most consult friction comes from one of two problems: unclear expectations or excessive noise. This four-step structure solves both.

1) Introduce yourself and your role

A simple intro sets a professional tone and removes ambiguity.

Script:

“Hey, this is Swami, one of the ED attendings. I’m calling for an ortho consult.”

2) Lead with the outcome (the ask)

Don’t bury the lede. The consultant wants to know what you need—immediately.

Script:

“I’m calling about a patient with a suspected septic knee. I need you to evaluate for operative management.”

3) Give a focused, decision-relevant summary

Your summary should answer:

• Why this is your service’s problem
• What’s already been done
• What I’m worried about / what decision is needed now

Script:

“43-year-old man with no major PMH, 3 days of knee pain and swelling. XR negative. Febrile. Aspiration yielded purulent fluid—cultures sent. We started antibiotics after the tap. He’s hemodynamically stable.”

High-yield pearl: Add quick “stability anchors” when relevant:

• “Airway stable, pain controlled.”
• “Neurovascularly intact.”
• “No signs of compartment syndrome.”
• “No hypotension or escalating oxygen requirement.”

4) Close the loop (timeline + next steps)

This prevents the consult from floating in limbo and protects patient flow.

Script:

“When do you expect to see the patient, and do you want anything done before you arrive—NPO, repeat labs, additional imaging?”

📝 ED Consult Script

General ED Consult Script

“Hi, this is Dr. ___ in the ED. I’m calling for a ___ consult. The reason is ___. Briefly: ___ year-old with ___. We’ve done ___ and started ___. I’m concerned about ___. Can you see them today, and what’s your preferred next step?”

Septic joint / Ortho Example

“Hi, this is Swami in the ED. I need an ortho consult for suspected septic arthritis. 43-year-old with 3 days of atraumatic knee swelling and fever. XR negative. Tap produced purulent fluid—cultures sent. Antibiotics started after aspiration. Can you evaluate for operative management, and when can you see the patient?”

Neurology example (time-sensitive)

“Hi, this is Dr. ___ in the ED. I need neurology for suspected acute stroke. Last known well ___. NIHSS ___. CT/CTA completed (or pending). I’m calling to discuss candidacy for thrombolysis/thrombectomy and next steps. When can you evaluate and what additional workup do you want now?”

⛓️‍💥 Common ED Consult Mistakes (and Fixes)

Mistake: Long story before the ask

Fix: Lead with the outcome in the first sentence

Mistake: Unfiltered data dump

Fix: Provide only decision-relevant details

Mistake: No timeline

Fix: Ask explicitly when they’ll see the patient and what they need first

Mistake: Implicit “ownership”

Fix: Clarify who is admitting, who is following, and what happens if the patient worsens

✋ What to Do When a Consultant Pushes Back

Even a perfect consult can meet resistance. Your job is to stay calm, keep it professional, and protect the patient.

1) Ask “why?”

Don’t argue first—diagnose the refusal.

Script:

“Help me understand your concern about seeing this patient.”

Many refusals are based on misunderstanding: wrong service, missing key detail, or incorrect assumption about stability.

2) Restate the consult in one sentence, then offer options

If the conversation starts spiraling, reset it.

Script:

“To be clear, I’m concerned this is septic arthritis and needs ortho evaluation. If you don’t feel you’re the right service, who should be—rheum, medicine, or another surgical team?”

This keeps you collaborative while preventing dead ends.

3) Humanize the decision (use sparingly)

This is a “high-voltage” tool. Use it when stakes are high and you’ve already clarified the medical facts.

Script:

“I’m worried we’re missing something time-sensitive. If this were your family member, what would you want us to do next?”

Use it to re-anchor to patient risk—not as a guilt tactic.

⚡️When and How to Escalate a Consult

Escalation isn’t personal—it’s a safety mechanism when there’s an impasse that threatens timely care.

When to escalate

• Time-sensitive condition is delayed (e.g., septic joint, cord compression, testicular torsion, GI bleed with instability)
• No clear disposition plan despite reasonable ED evaluation
• Consultant refusal blocks needed specialty decision-making
• Patient safety or deterioration risk is increasing in the ED

How to escalate (lowest to highest intensity)

1. Ask for the consultant’s attending (if speaking to a resident)
2. Call the on-call attending directly
3. Involve ED leadership/medical director
4. Escalate to service chief/department chair (rare, but real)
5. Hospital supervisor/admin escalation for immediate operational impasse

Script:

“We’re at an impasse and the patient needs a decision. I’m escalating to clarify ownership and ensure timely care.”

️ Documentation Tips for Consult Refusals

Documentation should be factual and patient-centered, not punitive.

Include:

• Your clinical concern and why the consult is needed
• Who you spoke with (name/role)
• Their stated reason for refusal or delay
• Alternatives discussed
• Escalation steps taken and final plan

👉 FAQ: Emergency Medicine Consults

What is the best way to call a consult in the ED?

Introduce yourself, lead with the specific ask, summarize only decision-relevant details, and close the loop with a clear plan and timeline.

What should I say when a consultant refuses to see a patient?

Ask why, clarify misunderstandings, restate your concern and the ask, and request an alternative plan or appropriate service.

When should I escalate a consult?

Escalate when an impasse delays time-sensitive care, threatens patient safety, or prevents appropriate disposition.

How do I document a refused consult?

Document the clinical concern, who you spoke with, their stated reason, alternatives discussed, and escalation steps taken.

🏁 Conclusion

Mastering emergency medicine consults makes you faster, safer, and easier to work with. The goal isn’t to “win” a consult call—it’s to get the patient the right care, with clear ownership and a shared plan.

Post Peer Reviewed By: Marco Propersi, DO (Twitter/X: @Marco_propersi), and Mark Ramzy, DO (X: @MRamzyDO)

👤 Associate Editor

Anand Swaminathan MD, MPH

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🧭 REBEL Rundown

📌 Key Points

• 💨 HFNC met criteria for non-inferiority to BPAP for preventing intubation or death within 7 days in four of the five ARF subgroups.
• 🧪 Bayesian dynamic borrowing increased power across subgroups but created variable certainty, especially in smaller groups such as COPD.
• 🫁 The immunocompromised hypoxemia subgroup did not meet non-inferiority, leading to early trial stopping for futility.
• ️ Rescue BPAP use, subgroup-specific exclusion criteria, and non-standardized BPAP delivery are important contextual factors that influence how subgroup results should be interpreted.

Click here for Direct Download of the Podcast.

📝 Introduction

• Bilevel Positive Airway Pressure (BPAP) has long been a foundational modality in the management of acute respiratory failure (ARF), particularly in COPD exacerbations and cardiogenic pulmonary edema, where it can rapidly reduce work of breathing and improve gas exchange. It remains a core tool in our respiratory support arsenal.

• High-flow nasal cannula (HFNC), however, has expanded what we can offer patients by delivering many of the same physiologic benefits through a far more comfortable interface. With high flows, modest PEEP, and effective dead-space washout, HFNC can improve oxygenation and decrease work of breathing while preserving the ability to talk, cough, eat, and interact with staff and family. This combination of physiologic support and tolerability makes HFNC especially attractive in patients where comfort, anxiety, or cardiovascular stability are key considerations, and in settings where prolonged noninvasive support may be needed. Rather than competing with BPAP, HFNC broadens our options in ARF and allows us to better match the modality to the patient and their underlying disease process.

• The RENOVATE trial set out to answer a high-impact question across five distinct etiologic groups: Is HFNC non-inferior to BPAP (NIV) for preventing intubation or death in acute respiratory failure?

🧾 Paper

Azoulay É, et al. High-Flow Nasal Oxygen vs Noninvasive Ventilation in Patients With Acute Respiratory Failure: The RENOVATE Randomized Clinical Trial. JAMA. 2025 PMID: 39657981

🔙Previously Covered On REBEL:

• HFNC: Part 1 – How It Works
• HFNC: Part 2 – Adult and Pediatric Indications
• FLORALI and AVOID Trial
• FLORALI-2: NIV vs HFNC as Pre-Oxygenation Prior to Intubation
• The Pre-AeRATE Trial – HFNC vs NC for RSI

️ What They Did

CLINICAL QUESTION

Is HFNC non-inferior to BPAP for rate of endotracheal intubation or death at 7 days in patients with acute respiratory failure due to a variety of causes?

STUDY DESIGN

• Multicenter, randomized non-inferiority trial
• 33 Brazilian hospitals
• Nov 2019 – Nov 2023
• Adaptive Bayesian hierarchical modeling with dynamic borrowing
• Open label, outcome adjudicators blinded
• Patients were classified into 5 subgroups

SUBGROUPS

1. Non-immunocompromised hypoxemia

• SpO₂ < 90% on room air or
• PaO₂ < 60 mm Hg on room air plus
  • Increased respiratory effort (accessory muscle use, paradoxical breathing, thoracoabdominal asynchrony) or
  • Respiratory rate > 25 breaths/min

2. Immunocompromised hypoxemia

Defined as:

• • Use of immunosuppressive drugs for >3 months
  • OR high-dose steroids >0.5 mg/kg/day
  • OR solid organ transplant
  • OR solid tumors or hematologic malignancies (past 5 years)
  • OR HIV with AIDS / primary immunodeficiency

3. COPD exacerbation with acidosis

• High clinical suspicion of COPD as primary diagnosis
• RR >25 with accessory muscle use, paradoxical breathing, and/or thoracoabdominal asynchrony
• ABG: pH <7.35 AND PaCO₂ >45

4. Acute cardiogenic pulmonary edema (ACPE)

• Sudden onset dyspnea and rales
• ± S3 heart sound
• No evidence of aspiration, infection, or pulmonary fibrosis
• CXR consistent with pulmonary edema

5. Hypoxemic COVID-19 (added June 2023)

• Added due to deviations between expected and observed outcome proportions
• Any patient across the other 4 groups with PCR-confirmed SARS-CoV-2 infection in any of the above groups

POPULATION

Inclusion Criteria:

• ≥18 yrs with ARF* in one of 5 pre-defined subgroups excluding COPD was defined by the following:
  Hypoxemia with SpO₂ <90 or PaO₂ <60
• Accessory muscle use, paradoxical breathing, and/or thoracoabdominal asynchrony
• RR >25 BPM

Exclusion Criteria:

• Need for emergency intubation
• Prolonged apneic episodes
• Cardiorespiratory arrest
• GCS <12
• HR <50 with decreased consciousness
• ABG pH <7.15
• Severe agitation requiring heavy sedation
• Hemodynamic instability (MAP <65, SBP <90 despite fluids or requiring high-dose pressors)
• Contraindications to BPAP (facial trauma, recent esophageal surgery, copious secretions, vomiting, aspiration risk)
• Pneumothorax or large pleural effusion
• Severe arrhythmia
• Thoracic trauma as primary ARF cause
• Asthma attack
• Cardiogenic shock
• ACS requiring urgent cath
• ARF within 72h post-extubation
• Post-surgical ARF within 72h
• Hypercapnic ARF due to neuromuscular/chest wall disease
• Palliative care or DNI
• Chronic pulmonary disease other than COPD
• 6 hours BPAP prior to randomization (hypoxemic non-immunocompromised, immunocompromised, and COPD groups)
• Prior BPAP use in ACPE

INTERVENTION & COMPARATOR

Intervention (HFNC Group):

• Flow:
  • COPD: Start 30 L/min
  • All others: Start 45 L/min
  • Titrated up to 60 L/min or highest tolerated
• FiO₂:
  • Start at 50% and titrate to maintain target SpO₂
• SpO₂ Targets:
  • COPD: 88–92%
  • Others: 92–98%

• Rescue Therapy (COPD & ACPE only):

  • If failing maximal HFNC → 1 hour of rescue BPAP
  • If failing BPAP → immediate intubation
• Weaning
  • Begin ≥24 hrs once RR <25 and no distress
  • Gradual reductions in FiO₂/flow
  • Considered weaned at:
    • FiO₂ <30% and Flow <25–30 L/min

Comparator (BPAP Group):

• Via ICU ventilator or BiLevel device
• Initial Settings:
  • COPD: IPAP 12–16 / EPAP 4
  • Others: IPAP 12–14 / EPAP 8
• Max settings: IPAP 20 / EPAP 12
• SpO₂ Targets:
  • COPD: 88–92%
  • Others: 92–98%
• Titration: Not standardized
• Sedation: Not standardized
• Weaning:
  • After 24 hrs
  • At clinician discretion
  • Considered weaned at FiO₂ 30% and EPAP/PS <6

OUTCOMES

Primary Outcome:

• Endotracheal intubation or death within 7 days.

Secondary Outcomes:

• 28-day mortality
• 90-day mortality 
• Mechanical ventilation free days at 28 days
• ICU-free days at 28 days

Tertiary Outcomes:

• Hospital and ICU length of stay within 90 days
• Vasopressor-free days within 28 days
• New DNI orders within 7 days
• Patient comfort

 

📈 Results:

💥 Critical Results

MOR: Median Odds Ratio
MHR: Median Hazard Ratio

💪 Strengths

• Broad, multicenter design: Large multicenter randomized trial comparing HFNC vs BPAP across several etiologies of acute respiratory failure in ED and ICU settings.
• Etiology-based and COVID-specific subgroups: Patients were stratified into prespecified clinical subgroups (COPD with acidosis, ACPE, immunocompromised hypoxemia, non-immunocompromised hypoxemia), and COVID-19 was later added and analyzed as a separate subgroup rather than being combined with the original ARF categories.
• Bayesian hierarchical model with dynamic borrowing: The primary analysis used a Bayesian hierarchical framework that allowed information to be borrowed across subgroups when treatment effects were similar and reduced borrowing when subgroups differed.
• Prespecified non-inferiority and futility rules: Each subgroup had predefined non-inferiority and futility boundaries, and enrollment in the immunocompromised subgroup was stopped early after crossing a futility threshold.
• Standardized BPAP delivery system: BPAP was delivered using a single BPAP system/interface across participating centers.
• Single healthcare system and population: All sites were within one national healthcare system, with broadly similar clinician training, practice patterns, and patient populations for that country.
• Current practice relevance: The trial addresses a post-COVID era question in which HFNC is widely used, providing comparative HFNC vs BPAP data across multiple ARF etiologies in a pragmatic ED/ICU population.

⚠️ Limitations

• Small subgroup sizes: The COPD (35 vs 42) and immunocompromised (28 vs 22) subgroups included relatively few patients compared with the other etiologic groups.
• Dependence on borrowing for COPD estimates: COPD treatment-effect estimates in the primary model were heavily influenced by borrowing from other subgroups, and no-borrowing sensitivity analyses showed wider intervals.
• Pre-randomization BPAP and exclusion criteria: COPD patients could receive up to 6 hours of BPAP before randomization, and ACPE patients judged to require immediate BPAP were excluded from enrollment.
• Rescue BPAP in the HFNC arm: Patients assigned to HFNC could receive rescue BPAP; BPAP settings were not standardized, and detailed reporting of rescue BPAP management and outcomes (including number of episodes) was limited.
• Non-standardized weaning strategies: Weaning protocols for HFNC and BPAP were not tightly protocolized or aligned, and HFNC weaning permitted flows down to 25–30 L/min.
• Single-country setting: All participating centers were located in one country.

🛣️Side Tangent on Bayesian Adaptive Model

• Prior to our deep dive into the discussion, lets first explain the importance of the statistical method used in the RENOVATE trial, the Bayesian Adaptive Model.
  
  
• A Bayesian Adaptive Model is a trial design that keeps updating its understanding of which treatment works better as new data are collected, and it allows the trial to change course in real time based on those results.
  
  
• Now imagine you’re comparing two pairs of running shoes. Your goal is to see which one helps runners finish faster, so you measure their race times. Runners try Shoe A or Shoe B, and as the results come in, you analyze the times.

• • If runners wearing Shoe A and Shoe B are finishing within a few seconds of each other, you would conclude the shoes perform similarly,  meaning they are non-inferior.
    
    
  • If runners wearing one shoe are consistently finishing much faster, you can say that shoe is superior, and the trial may stop early because you’ve clearly found the better option.
    
    
  • If one shoe repeatedly produces slower times compared to the standard, you may stop the trial for inferiority, because continuing would not benefit runners.
    
• This approach allows the study to learn as it goes and make decisions based on accumulating evidence rather than waiting until the very end.
  
  
• The Bayesian adaptive model also utilizes a statistical tool known as dynamic borrowing. Dynamic borrowing is a statistical method that allows data from related groups to be shared or pooled when their outcomes appear similar, but automatically reduces or stops that sharing when the groups differ, ensuring accuracy and preventing misleading conclusions.
  

• For example, if Shoes A and B are producing similar race times (non-inferior), the coach can combine or “borrow” data from both groups and average their times, which increases statistical precision.
  
  
• However, if one shoe becomes clearly superior or clearly inferior, dynamic borrowing stops, because the race times are no longer comparable and averaging them would distort the results.
  
  
• In this running-shoe analogy, the RENOVATE trial was essentially comparing Shoe A (BPAP) and Shoe B (HFNC) to see which helped patients “run faster,” or achieve better clinical outcomes in 5 different pathologies.
  
  
• In this running-shoe analogy, the RENOVATE trial was essentially comparing Shoe A (BPAP) and Shoe B (HFNC) to see which helped patients “run faster,” or achieve better clinical outcomes across five different respiratory pathologies. As results accumulated, the Bayesian adaptive model used dynamic borrowing and could combine results when both devices performed similarly, but stopped pooling data if one clearly helped patients more or less.

🗣️ Discussion

• What RENOVATE asked and what it found: The RENOVATE trial is the first multicenter randomized study to directly evaluate whether HFNC is non-inferior to BPAP for preventing intubation or death across multiple etiologies of acute respiratory failure. Overall, HFNC met non-inferiority criteria in four of the five predefined subgroups, with much of the statistical strength coming from the Bayesian borrowing structure. However, several design and analytic choices limit how confident we can be in these findings across all groups.
• Bayesian model, borrowing, and small numbers: The Bayesian hierarchical model improves precision by “sharing” information between subgroups when outcomes look similar, but this does not fully fix the problem of small sample sizes. In subgroups with low numbers, the model still has less power and more uncertainty, and the apparent stability of the estimates is heavily influenced by the borrowing framework rather than large, subgroup-specific datasets.
• COPD and ACPE – who actually got randomized: In both COPD and ACPE, enrollment decisions likely removed many of the sickest patients from randomization. COPD patients could be stabilized for up to six hours on BPAP before being randomized, and ACPE patients who clearly required immediate BPAP were excluded altogether. Because the trial never reported how many patients were treated or excluded in the ACPE group, we do not have a clear picture of how sick the randomized patients really were.
• Rescue BPAP in the HFNC arm: Rescue therapy adds another layer of ambiguity. Nearly a quarter of COPD patients in the HFNC arm required rescue BPAP, yet the study did not describe the BPAP pressure settings used, how many times rescue could be repeated, or whether these patients ultimately improved, failed, or required intubation. This is particularly important because the primary endpoint is intubation within seven days, and we do not know how much non-standardized BPAP rescue influenced that outcome in patients initially assigned to HFNC.
• Different weaning strategies between HFNC and BPAP: Weaning practices also differed meaningfully between HFNC and BPAP. HFNC patients could be considered “weaned” while still receiving flows that are well above physiologic baseline (25–30 L/min), whereas BPAP weaning was left largely to clinician judgment without tightly aligned criteria. This lack of standardized weaning makes it difficult to directly compare the two modalities in terms of duration of support and when a treatment should be considered to have “failed.”
• Value of multiple etiologic subgroups: Rather than asking a single global question of whether HFNC works for all causes of acute respiratory failure, the trial was designed with multiple etiologic subgroups. This allows us to compare HFNC and BPAP within distinct pathologies commonly seen in the ED and ICU. In practice, this design helps us look across each subgroup and think about which modality—HFNC or BPAP—may be most appropriate for a given underlying diagnosis.
• Immunocompromised subgroup had early futility and inadequate support: In immunocompromised patients, HFNC clearly underperformed BPAP on early outcomes. Intubation rates were higher with HFNC (50.0% vs 31.8%), and early deaths were also higher (17.9% vs 13.6%), leading this subgroup to cross a prespecified futility boundary and stopping further enrollment. By 28 and 90 days, mortality was similar between HFNC and BPAP in this cohort, suggesting that HFNC alone did not provide enough up-front respiratory support for this high-risk group rather than causing a lasting difference in long-term outcomes.
• Why COVID was separated from the original ARF subgroups: Early in the COVID-19 pandemic, clinicians were making treatment decisions in real time without established guidelines or a solid understanding of disease trajectory. Many COVID patients behaved clinically like an immunocompromised or atypical ARF cohort. If COVID patients had been left inside the original ARF subgroups, they could have distorted those results and biased the trial toward an apparent signal of HFNC futility. By separating COVID into its own subgroup, the investigators preserved the integrity of the non-COVID etiologic groups while still including COVID patients in the overall study population. This approach allowed for cleaner estimates within each subgroup and more appropriate borrowing across groups without letting a large, atypical population dominate the model.
• Standardized BPAP delivery as a control: Using one BPAP delivery method for all patients created a built-in control on the BPAP side of the trial. The interface and mode were standardized, so the main difference between patients was their underlying disease and assignment to HFNC vs BPAP. This consistency across BPAP subgroups reduces “noise” in how BPAP was delivered and makes it easier to attribute differences in outcomes to the disease process and modality choice rather than variation in the BPAP setup itself.
• Single-country setting and external validity: Running the entire study in one country means clinicians share similar training, practice patterns, and system-level resources, which helps keep management more consistent across subgroups and centers. The trade-off is external validity: what is considered “standard” care in this health system may look very different in other countries, particularly in resource-limited settings, so these findings may not translate perfectly to other practice environments.

📘 Author's Conclusion

“HFNC met criteria for noninferiority to NIV for the primary outcome in 4 of the 5 patient groups. Small sample sizes and sensitivity to the analysis model suggest further study is needed in COPD, immunocompromised patients, and ACPE.”

💬 Our Conclusion

HFNC appears to perform comparably to BPAP in non-immunocompromised hypoxemic and COVID-positive patients. However, the data in COPD, ACPE, and immunocompromised patients are limited and statistically fragile—heavily influenced by small numbers and modeling assumptions—so BPAP  should remain the preferred modality when ventilatory support is clearly required and may offer more reliable benefit in these groups.

🚨 Clinical Bottom Line

HFNC is a great option for many patients with acute respiratory failure, but some patients clearly need BPAP up front. In patients with obvious BPAP-responsive physiology—such as COPD with acidosis, ACPE with increased work of breathing, or frank hypercapnia—or in those who are crashing at the door, BPAP remains the first-line choice. In more stable patients, especially those without a strong indication for BPAP, with limited hypercapnia, or where comfort and longer-term tolerance matter, HFNC is a reasonable first-line option for extra respiratory support while you closely watch their trajectory and stay ready to escalate.

📚 References

1. RENOVATE Investigators and BRICNet Authors.
   High-flow nasal oxygen vs noninvasive ventilation in patients with acute respiratory failure: The RENOVATE randomized clinical trial. JAMA. 2025;333(10):875–890.
   PMID: 39657981 
2. Tempo G, Grieco DL.
   Article review: The RENOVATE randomised clinical trial. European Society of Intensive Care Medicine (ESICM) Article Review. 2025.
   Available here
3. Roca O, Messika J, Caralt B, et al.
   Predicting success of high-flow nasal cannula in pneumonia patients with hypoxemic respiratory failure: The utility of the ROX index. J Crit Care. 2016;35:200–205.
   PMID: 27481760
4. Rochwerg B, Brochard L, Elliott MW, et al.
   Official ERS/ATS clinical practice guidelines: Noninvasive ventilation for acute respiratory failure. Eur Respir J. 2017;50(2):1602426.
   PMID: 28860265

Post Peer Reviewed By: Post Peer Reviewed By: Mark Ramzy, DO (X: @MRamzyDO), Frank Lodeserto, MD and Anand Swaminathan, MD (X: @EMSwami)

👤 Guest Contributor

Jonathan Bradshaw, DO
Emergency Medicine Resident (PGY-3)
Cape Fear Valley Medical Center
Fayetteville, NC

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🧭 REBEL Rundown

🔑Key Points

🛌 Rest isn’t a luxury; it’s a necessity and differs significantly from sleep in terms of mental and physical recovery needs.

🧠 Uncovering the seven types of rest can highlight diverse needs: physical, mental, sensory, creative, emotional, social, and spiritual.

🏃‍️ Rest from high-stress environments such as the ED is crucial for reducing exhaustion, enhancing decision-making, and maintaining empathy.

🔄 The necessity for intentional rest: tailor your rest strategies to meet personal recharge needs effectively.

🧐 Rest should be deserved, not earned—it’s a vital component of overall health and wellness, on par with nutrition and hydration.

Click here for Direct Download of the Podcast.

👀Previously Covered and Related Content:

• • REBEL Core Cast: Sleep Hygiene
  • Rebellion in EM: Care For Yourself – Sleep Hygiene
  • First10EM: Some Evidence For Working Night Shifts
  • REBEL MIND: Dunning Kruger Effect

📝 Introduction

Welcome to this episode of 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.

Today we are exploring the imperative topic of rest and why it’s not just about sleeping. The first of a two part series, hosted by Dr. Mark Ramzy with guests Dr. Maureen Aiad and Dr. Amil Badoolah, our discussion sheds light on the multifaceted nature of rest, especially in the demanding field of emergency medicine. If you’re a clinician striving to perform at your best under pressure, this episode offers valuable insights into achieving the rest you deserve.

Cognitive Question

How do healthcare professionals in high-stress environments distinguish between rest and sleep, and how can they effectively incorporate various types of rest into their routines to manage stress and improve performance?

💤How is Rest Different From Sleep?

• • Sleep is biological. It’s essential—but it’s only one form of recovery.
  • Rest, on the other hand, is intentional, multifaceted, and active. 
  • You can sleep for 8 hours and still feel depleted—because what you needed wasn’t sleep, it was rest—in a different dimension.

🏥How This Applies to the Emergency Department or ICU?

• • In the fast-paced, high-pressure world of the ED or ICU, medical professionals often overlook the importance of rest, perceiving it as unproductive. 
  • Yet, rest is crucial for maintaining cognitive function and emotional resilience. The unique concept of rest outlined in the ‘seven types of rest’ can be particularly beneficial. 
  • Understanding and implementing these can help practitioners handle the rigors of patient care and decision-making more effectively.

7️⃣The Seven Types of Rest

• • 1️⃣Physical Rest: Passive (like sleep) and active (like stretching, massage, gentle movement).
  • 2️⃣Mental Rest: Reducing decision fatigue. Tools like brain dumping, meditation, or taking real breaks during work.
  • 3️⃣Sensory Rest: This involves reducing the input from your senses, such as limiting screen time, turning off the lights, or enjoying quiet time.
  • 4️⃣Creative Rest: Reconnecting with awe. Nature, art, music—things that refill your inspiration tank
  • 5️⃣Emotional Rest: Being around people you don’t have to perform for. Saying “I’m not okay.” spaces and people where you can be your authentic self and be at peace
  • 6️⃣Social Rest: Taking space from draining interactions; spending time with life-giving people. 
  • 7️⃣Spiritual Rest: Connection to a greater purpose—faith, community, reflection, meditation

⏩Immediate Action Steps for Your Next Shift

1. **Identify Your Rest Needs**: Reflect on what kind of fatigue you’re experiencing and tailor rest activities accordingly, whether it’s sensory detox or emotional unwinding.
2. **Practice Sensory Rest**: Take brief moments to close your eyes, or step outside for fresh air to manage overstimulation during shifts.
3. **Plan Intentional Breaks**: Schedule specific times for rest that focus on particular dimensions you identify as lacking.
4. **Engage in Active Rest**: Incorporate activities like stretching or meditation during your breaks to enhance mental clarity and reduce physical exhaustion.
5. **Connect with Supportive Colleagues**: Seek interactions with peers who offer emotional and social support, promoting a healthy work-life balance.

🛌🏽The Many Aspects of What Makes Up Rest

• • Rest is multifaceted – it comes in more than one form
    
    
  • Rest is productive – it improves performance, decision-making, empathy
    
    
  • Rest is intentional – it requires thoughtful engagement, not autopilot. Make a real plan
    
    
  • Rest is layered – especially sensory, which uses all 5 senses
    
    
  • Rest is about input and detox – what you consume, and what you remove. Social rest is a good example
    
    
  • Rest is personal – one person’s recharge is another’s stressor
    
    
  • Rest is deserved, not earned – full stop.

Conclusion

Rest is a pivotal, multi-dimensional tool that extends beyond mere sleep. For healthcare professionals navigating the strenuous environment of an emergency setting, recognizing and implementing varied forms of rest can enhance overall well-being, decision-making, and patient care. Make rest a deliberate part of your routine, understand its different forms, and remember that it’s a necessity you deserve.

🚨 Clinical Bottom Line

Incorporating rest into your lifestyle aligns with the demands of your professional roles and personal health needs. By understanding and employing various types of rest, you not only support your individual wellness but also enhance your ability to care for patients effectively. Rest is vital; it is not a privilege earned but an essential right you deserve every day.

Further Reading

1. Dalton-Smith, S.
   Sacred Rest: Recover Your Life, Renew Your Energy, Restore Your Sanity. Hachette Nashville, 2017.
   
   
2. Dalton-Smith, S.
   The 7 Types of Rest: Seven Ways to Live a More Energized Life. Hachette Book Group, 2022
   
   
3. Abramson, A
   “Seven types of rest to help restore your body’s energy.” American Psychological Association, 6 May 2025,
   Link is Here

Meet the Authors

Mark Ramzy, DO

Co-Editor-in-Chief

Cardiothoracic Intensivist and EM Attending

RWJBH / Rutgers Health, Newark, NJ

Maureen Aiad, DO

Assistant Professor of Emergency Medicine

NYU Grossman Long Island School of Medicine, New York

Amil Badoolah, DO

Assistant Professor of Emergency Medicine

NYU Grossman Long Island School of Medicine, New York

REBEL Core Cast 119.0 – Sleep Hygiene

REBEL Core Cast 119.0 – Sleep Hygiene Click here for Direct Download of ...

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The post REBEL MIND – Rest Is Not Sleep: The Seven Dimensions of True Recovery appeared first on REBEL EM - Emergency Medicine Blog.

🧭 REBEL Rundown

🗝️ Key Points

• 💉 Hydrocortisone Saves Lives:
  The 2023 Cape Cod Trial (NEJM) showed a clear mortality benefit and reduced need for intubation in severe CAP patients treated with hydrocortisone.
• 📊 Guidelines Are Catching Up:
  The SCCM (2024) and ERS now recommend steroids for severe CAP, while ATS/IDSA updates are still pending.
• 🔥 Redefining “Severe”:
  Patients requiring high FiO₂ (>50%), noninvasive or mechanical ventilation, or PSI >130 meet criteria for steroid therapy — even outside the ICU.
• 🍬 Main Risk = Hyperglycemia:
  Elevated glucose was the most consistent adverse effect, but rates of GI bleed and secondary infection were not increased.
• 🧭 Early, Targeted Use Matters:
  Start hydrocortisone within 24 hours of identifying severity — especially in patients with high CRP (>150) or strong inflammatory response.

Click here for Direct Download of the Podcast.

📝 Introduction

Corticosteroids have long sparked debate in the treatment of bacterial pneumonia — once viewed with skepticism, now increasingly supported by high-quality evidence. In this episode, Dr. Alex Chapa joins the REBEL Core Cast team to explore how the 2023 Cape Cod Trial (NEJM) reshaped practice and guideline recommendations for severe community-acquired pneumonia (CAP).

📖 Historical Context & Long-Standing Skepticism

For decades, the use of steroids in pneumonia was controversial.

• • Early Use: Steroids entered practice in the 1940s and 50s for autoimmune inflammation, but there was immediate hesitation regarding secondary superinfections.
  • Mixed Data: From the 1980s to the 2000s, small studies emerged on severe pneumonia and ARDS, but the data was inconsistent. Different trials used varying definitions of “severe” pneumonia and different C-reactive protein (CRP) cutoffs, making the data “spread” and easy to “cherry pick” to support or deny a benefit.
  • Past Guidelines: This uncertainty was reflected in official guidelines:
    • 2007 (ATS/IDSA): The American Thoracic Society and the Infectious Diseases Society of America did not address the topic due to insufficient data.
    • 2019 (ATS/IDSA): Pre-COVID, the guidelines recommended against using corticosteroids in severe CAP. They acknowledged no benefit for non-severe pneumonia, but the data for severe pneumonia was considered too weak to endorse.
    • Pre-Trial Consensus: Prior to 2023, the consensus was to avoid steroids in non-severe pneumonia, while severe pneumonia remained a “gray area” with no treatment showing a clear mortality difference.

📜 The Landmark Cape Cod Trial (NEJM 2023)

The Cape Cod trial, published in the New England Journal of Medicine in 2023, reignited the discussion by providing robust, positive data.

• Trial Design: Phase 3, multi-center, double-blind, randomized, controlled trial.
• Intervention: 800 patients randomized to two groups, Hydrocortisone as a continuous infusion (200mg/day) versus a placebo infusion.
• Taper: On day 4, clinicians would decide whether to continue the infusion or begin a taper based on clinical response.
• Population: Patients with severe CAP, defined by meeting at least one of the following criteria:
  • Pneumonia Severity Index (PSI) > 130.
  • O2 by FiO2 ratio < 300.
  • Need for mechanical or non-invasive ventilation (with PEEP ≥ 5).
  • Need for high FiO2 (>50%) via non-rebreather or heated high flow.
• Primary Outcomes: Death for any cause 6.2% (hydrocortisone) vs 11.9% (placebo)
• Secondary outcomes:
  • Death from any cause at 90 days 9.3% (hydrocortisone) vs 14.7% (placebo)
  • Endotracheal intubation 18% (hydrocortisone) vs 29% (placebo)
  • Hospital-acquired infections 9.8% (hydrocortisone) vs 11.1% (placebo)
  • Gastrointestinal bleeding 2.3% (hydrocortisone) vs 3.3% (placebo)
  • Vasopressor initiation by day 28 15.3% (hydrocortisone) vs 25.0% (placebo)
• Key Findings: The trial demonstrated superiority for hydrocortisone

📋 Updated Guidelines & Current Practice

The Cape Cod trial, along with subsequent meta-analyses, has begun to change official recommendations.

• Society of Critical Care Medicine (SCCM): In 2024, an SCCM expert panel, reviewing the Cape Cod trial and 18 others, strongly recommended corticosteroids for severe CAP. They concluded that steroids reduce mortality and the need for mechanical ventilation.
• Meta-Analysis (Smit et al.): A 2024 meta-analysis in Lancet Respiratory confirmed the 30-day mortality benefit.
• European Respiratory Society (ERS): The ERS has issued a recommendation to use steroids for severe pneumonia but still urges caution regarding side effects.
• ATS/IDSA: As of the podcast recording, the ATS/IDSA had not yet updated their 2019 guidelines.

🛠️ Practical Application for Clinicians

Defining “Severe” CAP: The key is to identify patients who qualify as “severe”. This can be done using:

• Scoring Tools: The PSI is the best validated tool for mortality but is cumbersome. Simpler tools like CURB-65 or SMART-COP are practical and acceptable for defining severity. 2023 meta-analysis from by Zaki et al showed both work well, but CURB-65 has better mortality prediction early on.
• Cape Cod Criteria: Any patient meeting the trial’s inclusion criteria (e.g., high-flow O2, non-invasive ventilation) qualifies, regardless of location (ED, floor, or ICU).
• Biomarkers: While not required, a CRP level was used in many studies. A CRP > 150 (Cape Cod) or > 204 (Smit meta-analysis) strongly indicates severe inflammation that would benefit from steroids.
• Clinical Judgment: A patient who looks “sick,” has “soft” blood pressure, or has dense infiltrates and high oxygen needs (e.g., >50% FiO2 on high flow) is a candidate.

Adverse Effects:

• Hyperglycemia: This was the most significant risk identified, with rates between 6-12%. This is a primary concern, especially in patient populations with high BMI.
• GI Bleed & Secondary Infection: Fears of these side effects, which contributed to historical skepticism, were not borne out in the Cape Cod trial. The data does not support being overly concerned.
• Other Side Effects: Mood changes, delirium, insomnia, and agitation in the elderly are known side effects of steroids that were not specifically addressed in the trial but remain clinical concerns.

🔄 Clinical Pathway for Steroids in Severe CAP

Unanswered Questions & Future Research

Possible remaining questions:

• Biomarkers: Can we find a more precise CRP level to distinguish moderate from severe disease? Could other markers like ferritin or IL-6 be used? 
• Dosing & Tapering: How much immunomodulation is needed, and when is it truly safe to taper?
• Gender Differences: Early data suggests females may respond better to steroids and experience fewer side effects. The question of female patients with severe CAP require less corticosteroids needs further exploration.

👉 Clinical Bottom Line

The current literature, spearheaded by the Cape Cod trial, now supports the use of corticosteroids in severe community-acquired pneumonia. The best evidence currently points to hydrocortisone, started early (within 24 hours) after severity is identified using a validated tool. While hyperglycemia is a risk, the previous fears of GI bleeding and secondary infections were not substantiated in recent, rigorous trials.

📚 References

1. Chapa-Rodriguez A, Abou-Elmagd T, O’Rear C, Narechania S.
   Do patients with severe community-acquired bacterial pneumonia benefit from systemic corticosteroids?. Cleve Clin J Med. 2025;92(10):600-604.
   PMID: 41033846
2. Dequin PF, Meziani F, Quenot JP, et al.
   Hydrocortisone in Severe Community-Acquired Pneumonia. N Engl J Med. 2023;388(21):1931-1941.
   PMID: 36942789
3. Chaudhuri D, Nei AM, Rochwerg B, et al.
   2024 Focused Update: Guidelines on Use of Corticosteroids in Sepsis, Acute Respiratory Distress Syndrome, and Community-Acquired Pneumonia. Crit Care Med. 2024;52(5):e219-e233.
   PMID: 38240492

Post Peer Reviewed By: Marco Propersi, DO (Twitter/X: @Marco_propersi), and Mark Ramzy, DO (X: @MRamzyDO)

👤 Show Notes

Alex Chapa, MD

PGY 5 Pulmonary Critical Care Fellow

Cape Fear Valley Medical Center

Fayetteville NC

🔎 Your Deep-Dive Starts Here

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The post REBEL Core Cast 149: Review of Corticosteroids in Community-Acquired Pneumonia 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 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

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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 exams
    • In 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 hospital

• • Allostatic 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 continues

Figure 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

1. Guidi J, et al.
   Allostatic Load and Its Impact on Health: A Systematic Review. Psychother Psychosom. 2021; Epub 2020 Aug 14.
   PMID: 32799204
2. Frueh 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.
• Indications
  • CPAP: 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

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🧭 REBEL Rundown

📌 Key Points

• 💀 Mortality: No statistically significant difference in 28-day mortality between ketamine vs etomidate for intubation in critically ill patients, though there was a ~1% absolute difference favoring ketamine. 📉
• 🫀⚠️ Hemodynamics: Ketamine induction was associated with more cardiovascular collapse, mainly driven by new/increased vasopressor use (dose escalation or addition of a vasoactive agent). 💉⬆️

Click here for Direct Download of the Podcast.

📝 Introduction

Etomidate or ketamine? The debate over the ideal agent for emergency rapid sequence intubation (RSI) has raged for years with no clear winner. Etomidate has been touted in the past for its rapid onset and minimal intrinsic effects on hemodynamics. However, the drug is well known as a transient adrenal suppressant though the impact of this suppression isn’t clear. Ketamine has risen in recent years as an alternative, due to its perceived hemodynamic stability, analgesic properties and absence of adrenal suppression. Additionally, recent data points towards improved mortality when ketamine was selected over etomidate (Kotani 2023). High quality randomized controlled trials are needed to further elucidate which agent should be selected in critically ill patients.

🧾 Paper

Casey JD et al. Ketamine or etomidate for tracheal intubation of critically ill adults. NEJM 2025. PMID: 41369227

🔙Previously Covered On REBEL

• REBEL EM: The EvK Trial: Ketamine vs Etomidate for Rapid Sequence Intubation
• REBEL EM: From Debate to Data: Emerging Insights into RSI Induction with Ketamine vs Etomidate

️ What They Did

CLINICAL QUESTION

In critically ill adults undergoing tracheal intubation, does the use of ketamine instead of etomidate result in improved 28 day mortality?

STUDY DESIGN

Multicenter, randomized, open-label trial in both emergency departments and ICUs.

POPULATION

Inclusion Criteria:

• Critically ill patients > 18 years of age undergoing tracheal intubation with the use of an induction agent

Exclusion Criteria:

• Known pregnancy
• Prisoners
• Primary diagnosis of trauma
• Need for immediate intubation precluding randomization
• Clinicians determined that the use of ketamine or etomidate was either necessary or contraindicated

INTERVENTION & COMPARATOR

Intervention (HFNC Group):

• Ketamine administered based on a provided nomogram: full dose (2.0 mg/kg), intermediate dose (1.5 mg/kg) or reduced dose (1.0 mg/kg)

Comparator (BPAP Group):

• Etomidate administered based on a provided nomogram: full dose (0.3 mg/kg), intermediate dose (0.25 mg/kg) or reduced dose (0.2 mg/kg)

OUTCOMES

• Primary: In-hospital death from any cause by day 28.

• Secondary:

• • • Cardiovascular collapse during intubation defined as SBP < 65 mm Hg, receipt of new or increased dose of vasopressors or cardiac arrest.

• Exploratory Procedural:

• • • Lowest systolic blood pressure
    • Lowest systolic blood pressure below 80 mmHg
    • Highest systolic blood pressure above 180 mmHg
    • Lowest oxygen saturation
    • Lowest oxygen saturation below 80%
    • Successful first attempt intubation
    • Time from induction to intubation

• Exploratory Clinical:

• • • Number of ventilator free days
    • Vasopressor-free days
    • ICU free days 

• Safety:

• •  Systolic blood pressure at 24 hours after enrollment
  • Ongoing receipt of vasopressors at 24 hours

📈 Results:

• 2365 patients were randomized
  • Ketamine: 1176
  • Etomidate: 1189
• > 99% of patients received the drug they were randomized to receive
• NMBA: 69% of patients in both groups received rocuronium
• ~ 95% of patients had video laryngoscopy for the primary intubation attempt

💥 Critical Results

💪 Strengths

• Multicenter ED + ICU cohort of critically ill patients → improves external validity
• Strong randomization → balanced baseline characteristics
• Right population for the question → appropriately focused on a sick cohort where induction choice matters most
• High protocol adherence → most patients received the agent they were randomized to
• Excellent follow-up → minimal loss to follow-up / outcome capture

⚠️ Limitations

• No blinding → potential performance/resuscitation bias
• Trauma excluded → limits applicability to peri-intubation trauma care
• Case-mix skewed toward septic shock → may reduce generalizability to other shock etiologies
• Power assumptions → designed to detect a 5% mortality difference (possibly overly ambitious)
• Equipoise-only enrollment → excluded patients with clear indication/contraindication → selection bias + reduced real-world applicability
• Composite secondary outcome with non-equivalent endpoints (e.g., cardiac arrest vs vasopressor titration)
• Ketamine dosing by actual body weight (vs ideal) → may have increased dose/exposure in some patients

🗣️ Discussion

• The increase in cardiovascular collapse seen with ketamine was driven by the “new or increased vasopressor use” piece of the composite outcome not by the more clinically relevant severe hypotension (SBP < 65 mm Hg) or cardiac arrest.
• The increase in CV collapse is a secondary outcome and hypothesis generating only
• Care beyond induction agent isn’t clearly delineated and may have varied between groups
• Reasons why there was more CV collapse in the ketamine group:
  • Patients in the etomidate group were more likely to be on pressors or have pressor increases prior to induction agent administration
  • Ketamine has analgesic properties which may affect hemodynamics (etomidate does not have analgesic effects)
  • The standard ketamine dose of 2 mg/kg is higher than the induction dose used by most (1-1.5 mg/kg)
  • Ketamine dosing was based on actual body weight though ideal body weight dosing is more accepted. This may have resulted in unnecessarily large ketamine doses that may have had a greater effect on hemodynamics.
• This is a study of patients with clinical equipoise
  • Patients who the clinician determined would clearly benefit from one agent or the other or in whom one agent or the other was contraindicated were excluded from the study.
  • This may add a selection bias to the results.
• Clinicians were not blinded to the induction agent administered
  • The absence of blinding can introduce bias.
  • For instance, knowledge of the agent the patient was randomized to may result in different resuscitative treatment prior to intubation.
• An induction agent nomorgram was provided to allow clinicians to choose their induction dose depending on patient stability.
• A 5% difference in mortality may be overly ambitious. As Josh Farkas points out in his post on this article, PCI for STEMI only has a 3% absolute difference in mortality versus standard care.
• The 1% absolute difference in mortality while not statistically significant would be clinically significant if it was real. 
  • The study would have to be much larger to show a statistically significant 1% difference.
• About 2% of patients in each group received additional medications during induction (propofol, benzodiazepines, opiates). It is unclear why these agents were selected in specific cases and how they may have affected the outcomes in question.

📘 Author's Conclusion

“Among critically ill adults undergoing tracheal intubation, the use of ketamine to induce anesthesia did not result in a significantly lower incidence of in-hospital death by day 28 than etomidate.“

💬 Our Conclusion

In this well done RCT, induction with ketamine did not result in a lower 28-day mortality when compared to induction with etomidate in critically ill adults. The secondary outcome of an increase in cardiovascular collapse is interesting and should be studied more in the future.

🚨 Clinical Bottom Line

This data should not drive clinicians to abandon the use of ketamine in RSI. To the contrary, the study leaves open the possibility of a clinically meaningful difference in mortality favoring ketamine that may be borne out in a larger study. However, etomidate can be considered as a first-line option for RSI and may be the superior drug in patients at high-risk for cardiovascular decompensation.

Post Peer Reviewed By: Post Peer Reviewed By: Mark Ramzy, DO (X: @MRamzyDO), Frank Lodeserto, MD and Anand Swaminathan, MD (X: @EMSwami)

📚 References

Kotani Y et al. Etomidate as an induction agent for endotracheal intubation in critically ill patients: a meta-analysis of randomized trials J Crit Care 2023;77:154317. PMID: 37127020

👤Associate Author

Anand Swaminathan MD, MPH

All Things REBEL EM

Meet The Team

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The post The RSI Trial: Ketamine vs Etomidate in Rapid Sequence Intubation 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, and

• Higher-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

1. Run a 60-second debrief on two cases
   What went well? What would I do differently next time?
   Write one improvement you’ll test today.
   
   
2. Play “What if the opposite were true?”
   Anchored on “lumbosacral strain”, Ask, What if fever/incontinence appears? How does that change my path?
   
   
3. Solicit 360° micro-feedback
   Ask a nurse, resident, and peer: “One thing I did well; one thing to improve.” Say “thank you,” not “but.”
   
   
4. Schedule a HALO refresher this week
   Pick one high-acuity, low-occurrence procedure (TVP, cric, thoracotomy).
   Do a 10-minute mental model + equipment walk-through; book sim time if available.
   
   
5. Adopt a pre-procedure pause
   If 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.
   
   
6. Language shift on shift
   Swap “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

1. Dunning D, Kruger J. Unskilled and Unaware of It (1999). Classic paper introducing the effect.
   
   
2. Croskerry P. Cognitive forcing strategies in clinical decision-making.
   
   
3. Kahneman D. Thinking, Fast and Slow. Heuristics & biases in high-stakes decisions.
   
   
4. Ericsson KA. Peak: Secrets from the New Science of Expertise. Deliberate practice & skill acquisition.
   
   
5. 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.