🌱 Growth mindset transforms learning – Residents and students who believe skills can be developed are more open to feedback, more resilient after failure, and more engaged in practice.
🧠 Language matters in feedback – Simple reframes such as “You’re developing procedural skills” instead of “You’re not strong at procedures” encourage persistence and normalize the learning curve.
🤝 Mindset shapes team culture – Growth mindset leaders foster psychological safety, invite input, and create collaborative teams. Fixed mindset hierarchies, on the other hand, silence voices and can compromise patient care.
🔥 Growth mindset protects against burnout – By reframing mistakes as part of the process, clinicians reduce perfectionism and shame, bolstering resilience and wellness.
🔍 Practical steps start with self-talk – Add the word “yet” to limiting beliefs (“I’m not good at X…yet”) and shift feedback questions toward improvement (“What’s one thing I can do better next time?”).
🛠️ Embracing mistakes with a growth mindset – Leads to more effective feedback loops and improvement do this by building a culture of psychological safety is crucial for growth and reducing medical errors.
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.
Mindset shapes everything we do in medicine—from how we teach and learn to how we show up for patients at the bedside. Drawing from Carol Dweck’s influential book Mindset, this episode of REBEL MIND explores the critical difference between a fixed mindset (believing abilities are innate and static) and a growth mindset (seeing skills as things that can be developed through effort and feedback).
We sat down with Dr. Kim Bambach, an emergency medicine physician and medical educator, and Dr. Frank Lodeserto, a dual-trained intensivist and internal medicine program director, to unpack how mindset influences medical education, bedside performance, and physician wellness. In this episode, we delve into how the mindset of clinicians can profoundly influence their performance, professional growth, and ultimately patient care
Cognitive Question
How does adopting a growth versus a fixed mindset influence clinical performance, medical education and patient outcomes?
🌱What is Growth vs Fixed Mindset?
In Carol Dweck’s research, two primary mindsets are highlighted:
Fixed mindset: Which sees intelligence and skills as static
In the medical field, adopting a fixed mindset might lead a clinician to avoid complex cases due to fear of failure.
Growth mindset: Which views abilities as improvable through dedication and effort.
In contrast, a growth mindset encourages embracing challenges as opportunities for learning and development.
🏥How This Applies to the Emergency Department or ICU?
In high-stakes environments like the ICU or the ED, the mindset adopted by healthcare providers can distinctly shape patient care and team dynamics.
A fixed mindset might lead to defensive behaviors and a reluctance to engage in challenging cases, potentially stunting personal and professional growth.
Conversely, a growth mindset not only fosters resilience and adaptability but also enhances team collaboration and patient outcomes by encouraging open communication, continuous learning, and acceptance of constructive feedback.
⏩Immediate Action Steps for Your Next Shift
**Monitor Self-Talk**: Notice your internal narrative when faced with challenges. Replace negative, fixed-mindset thoughts with growth-oriented ones like “Not yet” or “What can I learn from this?”
**Promote a Culture of Inquiry**: Challenge yourself and your team to engage in constructive questioning and explore alternative diagnoses or treatment plans to encourage a growth-centered environment.
**Model Vulnerability**: Share personal learning experiences and mistakes with colleagues to normalize the growth process and reduce the stigma of imperfection.
**Reframe Feedback**: Instead of broadly asking, “How did I do?” inquire, “What’s one thing I can improve on next time?” This shift helps maintain focus on growth rather than performance validation
Feedback is a whole another topic that we plan to have dedicated episodes and blog posts. This is an area where sometimes faculty struggle and often learners are asking for more/improved feedback.
💬Conclusion
Cultivating a growth mindset in medicine isn’t merely about staying positive; it’s about embracing continuous learning in the face of challenges. It involves creating supportive environments that encourage vulnerability, experimentation, and resilience. By adopting these practices, clinicians can improve not just personal competencies but also enhance patient care quality and safety.
🚨 Clinical Bottom Line
Clinicians who embrace a growth mindset not only enhance their skills but also contribute to a more dynamic, adaptive, and error-resilient healthcare environment. Remember, the best clinicians are those who never stop learning, not the ones who never make mistakes.
Episode Audio Edited By: Kim Bambach, MD and Mark Ramzy, DO (Twitter/X/IG: @MRamzyDO) Post Peer Reviewed By: Marco Propersi, DO (Twitter/X: @Marco_Propersi)
Further Reading and References
Claro S, Paunesku D, Dweck CS. Growth mindset tempers the effects of poverty on academic achievement. Proc Natl Acad Sci U S A. 2016 Aug 2. Epub 2016 Jul 18. PMID:27432947
Blackwell LS, et al. Implicit theories of intelligence predict achievement across an adolescent transition: a longitudinal study and an intervention. Child Dev. 2007 Feb; PMID: 17328703
Hopkins SR, et al. Trainee growth vs. fixed mindset in clinical learning environments: enhancing, hindering and goldilocks factors. BMC Med Educ. 2024 Oct 23 PMID: 39443909
Memari M, Gavinski K, Norman MK. Beware False Growth Mindset: Building Growth Mindset in Medical Education Is Essential but Complicated. Acad Med. 2024 Mar 1. Epub 2023 Aug 30. PMID: 37643577
Meet the Authors
Mark Ramzy, DO
Co-Editor-in-Chief
Cardiothoracic Intensivist and EM Attending
RWJBH / Rutgers Health, Newark, NJ
Kimberly Bambach, MD
Assistant Professor of Emergency Medicine
The Ohio State University Wexner Medical Center, Columbus, OH
Frank Lodeserto, MD
Internal Medicine Residency Program Director
Cape Fear Valley Medical Center, Fayetteville, NC
REBEL MIND – How to Sleep When the World Says You Can’t
mercredi 4 mars 2026 • Durée 27:30
🧭 REBEL Rundown
🔑Key Points
Try the coffee nap! Where you combine caffeine and a 30-minute nap to then have that boost energy and alertness by the time it kicks in.
💤 Sleep isn’t optional—it’s crucial for memory, mood regulation, and physical recovery. It is fundamentally different from rest
❌ Replacing sleep with caffeine isn’t effective and can have negative health impacts. Make getting enough sleep a priority
🌞 Sunlight exposure is important for maintaining circadian rhythms and sleep quality. This applies even if you work as a nocturnist
💡 Creating a personalized sleep system enhances quality and consistency. It gives you back control of a schedule that you may feel like is out of your hands.
🧩 If you’ve tried these strategies and you’re still struggling, consider true sleep pathology (insomnia, shift work disorder, sleep apnea) and get help—this is not a “be tougher” problem.
🩺 Better sleep isn’t just about feeling good; it’s directly tied to error reduction, patient safety, and longevity in EM/ICU careers.
📝 Introduction
Cognitive Question
💤How is Sleep Different From Rest?
🏥How This Applies to the Emergency Department or ICU?
🛏️Different Ways to Improve Your Sleep
⏩Immediate Action Steps for Before/During/After Your Next Shift
Conclusion
🚨 Clinical Bottom Line
Further Reading
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 MIND: Applying Performance Science In and Out of the Emergency Department
mercredi 18 février 2026 • Durée 34:03
🧭 REBEL Rundown
📌 Key Points
🔍 Understanding the Why: The significance of understanding underlying causes, beyond initial diagnoses, in both sports and emergency medicine is explored. ⏱️ Recovery Focus: Emphasizing the importance of recovery time and small daily choices in optimizing performance for both athletes and emergency physicians. 📊 Data-Driven Insights: The Arena Labs approach uses personalized data, leveraging wearable technology and expert coaching to tackle burnout and enhance well-being. 🤝 Personalization and Partnership: Arena Labs’ collaboration with emergency clinicians sheds light on personalized performance solutions rooted in scientific evidence.
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. Mark Ramzy interviews Allyn Abadie, Arena Labs’ Principal Scientist on how we can apply performance science in and out of the emergency department. 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
💭 Why This is Important
🏥How This Applies to the Emergency Department or ICU?
⏩ Things You Can Do on Your Next Shift
👀 Where to Learn More
🚨 Clinical Bottom Line
Meet the Authors
Mark Ramzy, DO
Co-Editor-in-Chief
RWJBH / Rutgers Health, Newark NJ
Allyn Abadie
Principal Scientist
Arena Labs
REBEL Core Cast 150.0: Emergency Medicine Consults: How to Call a Consult + Handle Pushback (With Scripts)
jeudi 12 février 2026 • Durée
🧭 REBEL Rundown
📌 Key Points
The 4 Steps of an ED Consult:
👋 Introduce yourself and your role
🎯 Lead with the outcome (the ask)
🧾 Give a focused case summary (why it’s theirs + what you’ve done)
🔁 Close the loop (timeline, next steps, contingencies)
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
2) Lead with the outcome (the ask)
3) Give a focused, decision-relevant summary
4) Close the loop (timeline + next steps)
📝 ED Consult Script
General ED Consult Script
Septic joint / Ortho Example
Neurology example (time-sensitive)
⛓️💥 Common ED Consult Mistakes (and Fixes)
✋ What to Do When a Consultant Pushes Back
1) Ask “why?”
2) Restate the consult in one sentence, then offer options
3) Humanize the decision (use sparingly)
⚡️When and How to Escalate a Consult
When to escalate
How to escalate (lowest to highest intensity)
️ Documentation Tips for Consult Refusals
👉 FAQ: Emergency Medicine Consults
What is the best way to call a consult in the ED?What should I say when a consultant refuses to see a patient?When should I escalate a consult?How do I document a refused consult?
🏁 Conclusion
👤 Associate Editor
Anand Swaminathan MD, MPH
🔎 Your Deep-Dive Starts Here
REBEL CAST – RENOVATE Trial: HFNC vs BPAP in Acute Respiratory Failure
jeudi 5 février 2026 • Durée 19:11
🧭 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.
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
🔙Previously Covered On REBEL:
️ What They Did
CLINICAL QUESTION
STUDY DESIGN
SUBGROUPS
POPULATION
INTERVENTION & COMPARATOR
OUTCOMES
📈 Results:
💥 Critical Results
💪 Strengths
⚠️ Limitations
🛣️Side Tangent on Bayesian Adaptive Model
🗣️ Discussion
📘 Author's Conclusion
💬 Our Conclusion
🚨 Clinical Bottom Line
📚 References
👤 Guest Contributor
🔎 Your Deep-Dive Starts Here
REBEL MIND – Rest Is Not Sleep: The Seven Dimensions of True Recovery
mercredi 4 février 2026 • Durée 20:22
🧭 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.
Welcome to this episode of REBEL MIND, where MIND stands for Mastering Internal Negativity during ifficulty. 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.
Cognitive Question
💤How is Rest Different From Sleep?
🏥How This Applies to the Emergency Department or ICU?
7️⃣The Seven Types of Rest
⏩Immediate Action Steps for Your Next Shift
🛌🏽The Many Aspects of What Makes Up Rest
Conclusion
🚨 Clinical Bottom Line
Further Reading
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 149: Review of Corticosteroids in Community-Acquired Pneumonia
lundi 2 février 2026 • Durée 14:20
🧭 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.
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.
📜 The Landmark Cape Cod Trial (NEJM 2023)
📋 Updated Guidelines & Current Practice
🛠️ Practical Application for Clinicians
🔄 Clinical Pathway for Steroids in Severe CAP
Unanswered Questions & Future Research
👉 Clinical Bottom Line
📚 References
👤 Show Notes
Alex Chapa, MD
PGY 5 Pulmonary Critical Care Fellow
Cape Fear Valley Medical Center
Fayetteville NC
🔎 Your Deep-Dive Starts Here
REBEL CAST – IncrEMentuM26 Speaker Spotlight : Drs. Sara Crager and Ryan Ernst
jeudi 29 janvier 2026 • Durée 36:38
🧭 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.
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.
🌳The Arboretum Teaching Collective
️ See you in Spain!
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 MIND: The Power of Performance Coaching in Medicine
mercredi 28 janvier 2026 • Durée 30:35
🧭 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.
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:
🤔Cognitive Question
💭 Why This is Important
🏥How This Applies to the Emergency Department or ICU?
⏩ Things You Can Do on Your Next Shift
👀 Where to Learn More
🚨 Clinical Bottom Line
Meet the Authors
Marco Propersi
Co-Editor-in-Chief
Vassar Brothers Medical Center, Poughkeepsie, NY
Jackie Pen
Head of Performance Coaching
Arena Labs
REBEL MIND: Performance Under Pressure – What Medicine Can Learn from Elite Teams
mercredi 21 janvier 2026 • Durée 39:11
🧭 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.
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
What is Allostasis and Allostatic Load
🏥How This Applies to the Emergency Department or ICU?
👀 Where to Learn More
🚨 Clinical Bottom Line
📚References
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
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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 second of a two part series, hosted by Dr. Mark Ramzy with guests Dr. Maureen Aiad and Dr. Amil Badoolah, continue our discussion but this time on the multifaceted nature of sleep, how it serves as medicine and how we can use our tools deliberately to get more of it!
How would your clinical performance, patience with families, and long-term career sustainability change if you treated sleep as a non-negotiable clinical intervention rather than a flexible “nice-to-have”?
1. Rest reduces load; sleep repairs systems
We previously talked about the 7 types of rest and you can check that out here
Examples of physical rest include: pausing tasks, stepping away from the monitor, taking a walk, stretching, breathing, journaling, connecting with a colleague. This lightens your cognitive/emotional burden.
Sleep is fundamentally different in that it’s an active biologic process that helps:
Consolidates memory and learning (yes, including the tough cases from last night).
Regulates mood, impulse control, and emotional reactivity.
Supports immunity, metabolic health, and cardiovascular function.
Repairs tissue, replenishes neurotransmitters, and fine-tunes neural networks.
You can have “rested but underslept” days (you took breaks but got 4 hours in bed), and “slept but unrested” days (you got hours, but all junk sleep). Both matter, but they are not interchangeable.
2. Sleep architecture vs. “knocking out”
True restorative sleep cycles through NREM and REM in predictable patterns.
Alcohol, late caffeine, and fragmented nights may help you fall asleep faster but:
Suppress REM.
Shorten deep sleep.
Increase awakenings and light sleep.
The result: you technically slept, but your brain didn’t get the “software updates” it needed.
Biology isn’t built for your schedule
Circadian rhythms were designed for light-day / dark-night cycles, not:
10 pm–7 am ED shifts.
24-hour calls.
6 nights in a row followed by days.
Your body can adapt partially, but not instantly and not perfectly. That’s why:
You can feel “jet-lagged” even when you haven’t traveled.
Sleep before and after nights feels odd and fragile.
Recognizing that “this is biologically unnatural” is key: you’re not weak; you’re fighting physiology.
Performance & safety
Sleep deprivation:
Slows reaction time and increases error rate.
Impairs risk assessment and complex decision-making.
Drops your frustration tolerance with consultants, families, and staff.
In both emergency medicine and critical care, that translates into:
Anchoring on the wrong diagnosis.
Missing subtle clinical changes.
Snapping at a tech, nurse or resident and damaging team culture.
Chronic health for chronic shift work Long-term sleep disruption is associated with:
Hypertension, diabetes, obesity.
Depression, anxiety, burnout.
Arrhythmias (e.g., AFib) and increased stroke risk.
Possibly increased all-cause mortality.
You’re already in a high-stress, high-exposure specialty. Chronically poor sleep amplifies that risk profile and can end a career early—or make you miserable while you’re still in it.
Culture of “heroics” vs. health
Skipping sleep to pick up extra shifts, late meetings, or “just one more note” is often praised.
We rarely celebrate:
The attending who says “no” to a 2 pm meeting post-nights.
The resident who defends their blackout-curtains-and-earplugs routine.
Clarify your “sleep non-negotiables”
Decide how many hours you realistically need to function (e.g., 7–9 on off days, realistic blocks on nights).
Treat those hours as you would a procedure time—blocked, protected, and respected.
Use caffeine like a drug, not a reflex
Aim for ≤ 2 cups equivalent on most days.
Avoid caffeine within 4–6 hours of your planned sleep time (remember: it can hang around up to 12 hours).
Consider scheduling caffeine for:
Early in the shift for alertness.
Strategic “coffee naps” (see below), not late-night chugging.
Respect alcohol’s impact on sleep
Recognize that even small to moderate doses degrade sleep architecture.
Avoid using alcohol as a “sleep aid”—you’ll fall asleep faster but sleep worse.
If you do drink, separate it from bedtime and keep it modest.
Optimize food and fluid timing
Hydrate consistently on shift, but taper fluids ~4 hours before bed to reduce nocturnal bathroom trips.
Avoid heavy, spicy, or large meals within 2–3 hours of sleep to decrease reflux and discomfort.
Plan a light, balanced “pre-sleep” snack if going to bed hungry keeps you awake.
Move your body (but not right before bed)
Regular exercise improves sleep depth and latency.
Try to avoid intense workouts within 2 hours of bedtime.
On shift: micro-movement (stairs, brisk walks between pods, quick stretch sessions) can help alertness without wrecking sleep later.
Control light exposure
Maximize sunlight or bright light after waking (even if that’s 3–4 pm after a night).
Minimize bright light and screens before sleep:
Dim lights.
Use night mode/blue-light filters if you must scroll.
For daytime sleep:
Use blackout curtains, tinfoil, cardboard, or sleep masks.
Yes seriously use tinfoil if you have to, we talk about it on the podcast episode!
Aim for “I might be blind” darkness—so dark you can’t see your hand in front of your face.
Dial in your sleep environment
Cool room temperature (fan or AC if possible).
White noise or sound machine to mask household/traffic noise.
Earplugs and eye masks as needed.
Bed used primarily for sleep (and sex)—not for charting, doom scrolling, or email.
Strategic power naps
Keep naps ≤ 20–30 minutes to avoid sleep inertia.
Prefer early-afternoon or pre-night-shift naps.
Coffee nap strategy:
Drink a small coffee.
Immediately lie down for a 20–30 min nap.
Wake up as the caffeine kicks in, combining nap benefit + stimulant.
Thoughtful melatonin use
Remember melatonin is a hormone, not a vitamin gummy.
Lower doses often work as well as (or better than) large OTC doses.
Use it intentionally and intermittently, not as a crutch every night.
Over-reliance may reduce your own natural production and its effectiveness over time.
Build pre-sleep rituals
Repeated, calming habits signal your body it’s time to downshift:
Warm shower, gentle stretching, or yoga.
Guided breathing or body scan.
Brief journaling or “brain dump” of tasks to get them out of your head and onto paper.
Protect from pathologic patterns
If despite consistent effort you:
Snore heavily, stop breathing, or gasp in sleep.
Feel excessively sleepy driving home or at work.
Cannot fall asleep or stay asleep for weeks to months.
Consider evaluation for sleep apnea, insomnia, or shift-work sleep disorder with your physician or sleep specialist.
1. **Before the Shift**:
Plan a 20–90 minute nap before your first night shift (many clinicians find 3–5 hours earlier in the day is ideal).
I treat ED and ICU shifts very differently. I always sleep 3-5 hours before my night shifts aiming for the full 5 (sometimes 6 or more) hours for my ED shifts because you always have to be “on”. Depending on the ICU I’m working in, I may have a bit more downtime so 3 to 5 hours is plenty.
Set a caffeine plan: decide in advance when your last dose will be (e.g., none after 2–3 am if sleeping at 8–9 am).
Tell your household, “This is my sleep block” and agree on a plan for kids, pets, deliveries, etc.
On my calendar, I completely block off time called “Pre-call sleep” so no meetings can be scheduled and then put my phone in airplane mode
2. **During the Shift**
Hydrate early; taper fluids in the last 3–4 hours of your shift
Eat something light but adequate; avoid “last-minute” heavy meals right before sign-out.
Build in micro-breaks and movement: one or two short walks, a few stretches, even a quick stair run if safe.
Get outside or near a window for a few minutes of light exposure if possible.
3. **After the Shift**
On the way home:
Use sunglasses to reduce bright morning light if you’re aiming for sleep soon.
Avoid “just checking” email or messages; shift into wind-down mode.
At home:
Do a brief, calming decompression (shower, light snack, 10–15 minutes of low-stimulation TV or reading).
Make your room cold, quiet, and dark (blackout curtains, tinfoil/cardboard, white noise, fan).
Put your phone on Do Not Disturb and physically place it away from the bed.
On my calendar, I completely block off time called “Post-call sleep” so again no meetings can be scheduled and then I personally don’t just put my phone on Do Not Disturb but rather in airplane mode and WIFI OFF
If you can’t sleep after ~20–30 minutes:
Get out of bed, do something calming in dim light (breathing, gentle stretching, journaling).
Return to bed when sleepy—this trains your brain to associate bed with sleep, not frustration.
Rest and sleep are both critical—but they’re not interchangeable. Rest helps you step out of the constant “on” of our jobs, while sleep is the biological intervention that restores your ability to show up safely and sustainably. Rest ≠ sleep. Rest reduces load; sleep repairs your brain and body. You need both, on purpose.
As EM and ICU clinicians, we’re trying to perform formula-one-level medicine with engines that often only see half their maintenance. You won’t fix shift work. You can build a sleep system that respects your biology, your schedule, and your life at home.
That system starts with valuing sleep, then prioritizing it, personalizing it, trusting the process when it’s imperfect, and actively protecting both your routine and your mindset.
Sleep is medicine. Shift work is biologically unnatural. Struggling does not mean you’re weak; it means you’re human fighting physiology. Use your tools deliberately. Caffeine, naps, light, food, movement, melatonin, and environment can be leveraged—or can quietly sabotage you. Build and defend a personalized sleep routine. Communicate it, normalize it, and protect it from casual encroachment. You can’t control every trauma, code, or admission—but you can control how seriously you take your own recovery. Your patients, your team, and your future self all benefit when you do.
Espie CA. The ‘5 principles’ of good sleep health. J Sleep Res. 2022 Jun; PMID: 34676592
Solodar, J
“Sleep hygiene: Simple practices for better rest.” Harvard Health, 31 January 2025 Link is Here
Suni, E.
“Mastering Sleep Hygiene: Your Path to Quality Sleep.” Sleep Foundation, 7 July 2025, Link is Here
How can emergency department clinicians utilize techniques inspired by athletic performance to better manage stress, prevent burnout, and optimize recovery?
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.
Emergency medicine, akin to high-performance sports, demands intense energy and quick decision-making under pressure, often leading to stress and burnout. By applying principles from athletic recovery and personalized data tracking, clinicians can moderate their performance intensity, enhance their recovery even in short breaks, and prevent long-term burnout. This approach allows emergency physicians to maintain endurance and clarity, improving patient care and team dynamics.
Measure and Reflect: Start tracking your vital health metrics like heart rate with wearable sensors. Reflect on how daily activities impact these measurements to identify stress patterns.
Implement Quick Recovery Techniques: Use short, actionable exercises such as deep breathing or the de-stress breath method between patient encounters to moderate stress levels.
Invest in Self-Care: Dedicate brief time slots for essential self-care activities like hydration or quick reflection journaling, aiming to enhance mental resilience throughout your shift.
Utilize Coaching Tools: Engage with personalized coaching apps or resources that offer science-backed recovery strategies tailored to your personal and professional needs.
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.
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.
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.”
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.”
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.”
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?”
“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?”
“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?”
“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?”
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
Even a perfect consult can meet resistance. Your job is to stay calm, keep it professional, and protect the patient.
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.
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.
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.
Escalation isn’t personal—it’s a safety mechanism when there’s an impasse that threatens timely care.
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
Patient safety or deterioration risk is increasing in the ED
Ask for the consultant’s attending (if speaking to a resident)
Call the on-call attending directly
Involve ED leadership/medical director
Escalate to service chief/department chair (rare, but real)
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 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
Introduce yourself, lead with the specific ask, summarize only decision-relevant details, and close the loop with a clear plan and timeline.
Ask why, clarify misunderstandings, restate your concern and the ask, and request an alternative plan or appropriate service.
Escalate when an impasse delays time-sensitive care, threatens patient safety, or prevents appropriate disposition.
Document the clinical concern, who you spoke with, their stated reason, alternatives discussed, and escalation steps taken.
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)
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
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?
Multicenter, randomized non-inferiority trial
33 Brazilian hospitals
Nov 2019 – Nov 2023
Adaptive Bayesian hierarchical modeling with dynamic borrowing
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 (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
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
MOR: Median Odds Ratio MHR: Median Hazard Ratio
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.
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.
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.
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.
“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.”
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.
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.
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
Tempo G, Grieco DL. Article review: The RENOVATE randomised clinical trial. European Society of Intensive Care Medicine (ESICM) Article Review. 2025. Available here
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
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)
Jonathan Bradshaw, DO Emergency Medicine Resident (PGY-3) Cape Fear Valley Medical Center Fayetteville, NC
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.
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?
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.
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.
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
**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.
**Practice Sensory Rest**: Take brief moments to close your eyes, or step outside for fresh air to manage overstimulation during shifts.
**Plan Intentional Breaks**: Schedule specific times for rest that focus on particular dimensions you identify as lacking.
**Engage in Active Rest**: Incorporate activities like stretching or meditation during your breaks to enhance mental clarity and reduce physical exhaustion.
**Connect with Supportive Colleagues**: Seek interactions with peers who offer emotional and social support, promoting a healthy work-life balance.
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.
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.
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.
Dalton-Smith, S. Sacred Rest: Recover Your Life, Renew Your Energy, Restore Your Sanity. Hachette Nashville, 2017.
Dalton-Smith, S. The 7 Types of Rest: Seven Ways to Live a More Energized Life. Hachette Book Group, 2022
Abramson, A “Seven types of rest to help restore your body’s energy.” American Psychological Association, 6 May 2025, Link is Here
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 Cape Cod trial, published in the New England Journal of Medicine in 2023, reignited the discussion by providing robust, positive data.
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
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.
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.
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.
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.
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
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
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)
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.
How do specific performance coaching strategies and tools assist healthcare professionals, particularly those in emergency medicine, in managing stress and preventing burnout effectively?
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.
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.
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
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.
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.
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?
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
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.
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.
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.
Guidi J, et al. Allostatic Load and Its Impact on Health: A Systematic Review. Psychother Psychosom. 2021; Epub 2020 Aug 14. PMID: 32799204
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
