The Critical Care Commute Podcast

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@nickmmark Love @CritCareTime by the way! Keep up the excellent, engaging work!!

@CriticalCommute Those are excellent points! Excited to listen

It’s fair to criticize the surviving sepsis guidelines but complaining about the number of pages or authors isn’t really the right criticism.

@Bram_Rochwerg @docpgb @Wilkinsonjonny @ICUltrasonica

NEW EPISODE: 2026 Surviving Sepsis Campaign guidelines — 88 pages, 69 authors, 129 recommendations, only 17 "strong." Vice-chair Prof. Bram Rochwerg joins us to unpack what changed. Live now. #CriticalCare #FOAMcc #ICU #MedEd #TheCriticalCareCommute

Here's the latest edition of Critical Care papers everyone is talking about! #FOAMed #POCUS #FOAMcc criticalcarenorthampton.com/episode-8-july…

Huge thanks to Prof. Sheldon Cheskes for breaking down refractory VF management on the Critical Care Commute Podcast. Full episode + more resources linked below. #CriticalCare #Resuscitation #FOAMed #EMS

Cheskes' own practice has moved past the trial protocol: AP pads from the start, minimal epi, early amio, straight to DSED after 3 failed shocks. The field keeps evolving.

What's next? Early data from Sweden's "Double D" trial testing DSED after just 1 failed shock: 41% survival vs. 9% with standard defib. Small sample, but the signal is consistent — earlier is better.

Protocol discipline > improvisation. Cheskes is clear: don't try DSED ad hoc mid-code because you read about it. It takes a drilled team and a defined 3-shock threshold.

Common mistake: lateral pads placed too low end up shocking soft tissue, not the ventricle. Pad position matters as much as the strategy itself.

It's not about more joules. Different defibrillators show different energy numbers, but it's the CURRENT through the myocardium that actually converts VF — and that's comparable across devices.

The DSED sequence: after 3 failed AL shocks → 30 compressions/vents → log-roll for posterior pad → another cycle → 1 min CPR → shock AL first, then AP ~500ms later.

Timing is everything. The longer a patient sits in VF, the more acidotic they get — and the less responsive to defibrillation. As Cheskes puts it: "In cardiac arrest, you do things late, people die."

Vector Change vs. DSED — know the difference: • VC: move the pads from AL → AP. One vector, changed once. • DSED: ADD AP pads to the existing AL pads, fire both defibrillators ~500ms apart.

DOSE-VF: a cluster-randomized crossover trial across 6 Ontario paramedic services, comparing standard defib, vector change, and DSED. Both alternatives showed significantly higher survival to hospital discharge than standard care.

Refractory VF isn't a rare edge case — it's a coin flip on every VF arrest you run. ~50,000 US OHCAs present in VF each year, and half of those patients need more than 3 shocks to convert.

Your patient is still in VF after 3 shocks. Now what? 50% of shockable OHCA patients fail standard defibrillation. We talked to Prof. Sheldon Cheskes, lead investigator of the DOSE-VF trial, about what actually works. 🧵

Donning PPE is rehearsed. Doffing is where self-contamination happens. Heat, sweat, exhaustion — that's when steps get skipped. The dofficer exists for exactly this reason. #CriticalCare #FOAMcc #ICU #MedEd #TheCriticalCareCommute