Books Currently Reading Mystery Three Pines (Chief Inspector Gamache) : The Madness of Crowds (#17) Thursday Murder Club : The Last Devil to Die (#4) Next in Line On Hold Charles Lenox Mysteries : Home by Nightfall (#9) and The Inheritance (#10) Civilizations Rise and Fall (Jared Diamond): Guns, Germs, and Steel: The Fates of Human Societies (#1) Books I Want to Read: Fiction Crime/ Mystery The Last Thing He Told Me Big Lies in a Small Town The Appeal All Good People Here Happiness Falls Mother-Daughter Murder Night The Cloisters Murder Your Employer: The McMasters Guide to Homicide A Most Agreeable Murder The Woman in the Library Crime/ Mystery: Series Nell Ward Mysteries : A Swarm of Butterflies (#6, expected August 2024) Detective Varg : The Strange Case of the Moderate Extremists (#0.8), The Talented Mr. Varg (#2), The Man with the Silver Saab (#3) and The Discreet Charm of the Big Bad Wolf (#4) Death in Paradise : A Meditation on Murder (#1), The Killing of Polly Carter (#2), Death Knocks Twice (#3), and Murder in the Caribbean (#4) Hawthorne and Horowitz : Close to Death (#5, expected April 2024) The Marlow Murder Club : The Queen of Poisons (#3, expected June 2024) Three Pines (Chief Inspector Gamache) : The Madness of Crowds (#17), A World of Curiosities (#18), and The Grey Wolf (#19, expected October 2024) Thomas De Quincey : Inspector of the Dead (#2) and Ruler of the Night (#3) Sam Clair : A Cast of Vultures (#3) and A Howl of Wolves (#4) Charles Lenox Mysteries : An East End Murder (#4.5), Home by Nightfall (#9), The Inheritance (#10), Gone Before Christmas (#10.5), The Woman in the Water (#11), The Vanishing Man (#12), The Last Passenger (#13), An Extravagant Death (#14), The Hidden City (#15) Castle Knoll Files : How to Solve Your Own Murder (#1) Verity Kent Mysteries : This Side of Murder (#1), Treacherous Is the Night (#2), Penny for Your Secrets (#3), A Pretty Deceit (#4), Murder Most Fair (#5), A Certain Darkness (#6), and The Cold Light of Day (#7) Kaely Quinn Profiler : Fire Storm (#2) and Dead End (#3) Cal Hooper : The Hunter (#2) Dr. Thomas Silkstone : The Dead Shall Not Rest (#2), The Devil’s Breath (#3), The Lazarus Curse (#4), Shadow of the Raven (#5), and Secrets in the Stones (#6) The Checquy Files : Stiletto (#2) and Blitz (#3) Letty Davenport : Dark Angel (#2) Terminal List : The Terminal List (#1), True Believer (#2), Savage Son (#3), The Devil’s Hand (#4), In the Blood (#5), Only the Dead (#6), and Red Sky Mourning (#7) Gabriela Rose : The Recovery Agent (#1) and The King’s Ransom (#2) Charlotte and Thomas Pitt Lady Sherlock Hercule Poirot (Agatha Christie) Kovac and Liska Assistant to the Villain D.I. Lottie Parker Cormac Reilly Stewart Hoag The Charity Shop Detective Agency Harbinder Kaur Lucas Davenport Erast Fandorin Mysteries Maisie Dobbs Historical Fiction Kate Quinn: The Huntress , The Diamond Eye Kristin Harmel: The Book of Lost Names , The Forest of Vanishing Stars , The Winemaker's Wife Marie Benedict: The Other Einstein , The Only Woman in the Room The Lost Girls of Paris The Nightingale The Lobotomist's Wife The Paris Library The Clockmaker's Daughter The Bookbinder Transcription Dangerous Women Science Fiction/ Fantasy Last Night in Montreal Hummingbird Salamander Recursion Science Fiction/ Fantasy: Series Borne : Borne (#1), The Strange Bird (#1.5), Dead Astronauts (#2) Winternight Trilogy : The Bear and the Nightingale (#1), The Girl in the Tower (#2), and The Winter of the Witch (#3) Novels/ Series Harold Fry : The Love Song of Miss Queenie Hennessy (#2) and Maureen (#3) The Hundred-Year-Old Man : The Accidental Further Adventures of the Hundred-Year-Old Man (#2) Ann Leary: The Good House and The Children Lonesome Dove The Book with No Pictures Books I Want to Read: Non-Fiction Business The Innovator's Dilemma: The Revolutionary Book that Will Change the Way You Do Business History Civilizations Rise and Fall (Jared Diamond): Collapse: How Societies Choose to Fail or Succeed (#2) and Upheaval: Turning Points for Nations in Crisis (#3) Climbing and Adventures Shackleton's Way: Leadership Lessons from the Great Antarctic Explorer Buried in the Sky: The Extraordinary Story of the Sherpa Climbers on K2's Deadliest Day Over the Edge of the World: Magellan's Terrifying Circumnavigation of the Globe Touching the Void: The True Story of One Man's Miraculous Survival The Next Everest: Surviving the Mountain's Deadliest Day and Finding the Resilience to Climb Again The Boys of Everest: Chris Bonington and the Tragedy of Climbing's Greatest Generation Forever on the Mountain: The Truth Behind One of Mountaineering's Most Controversial and Mysterious Disasters The Climb: Tragic Ambitions on Everest Climb: Stories of Survival from Rock, Snow and Ice Medical Nine Pints: A Journey Through the Money, Medicine, and Mysteries of Blood Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted Blood and Guts: A History of Surgery Confessions of a Surgeon: The Good, the Bad, and the Complicated...Life Behind the O.R. Doors Do No Harm: Stories of Life, Death and Brain Surgery You Can Stop Humming Now: A Doctor's Stories of Life, Death and in Between When We Do Harm: A Doctor Confronts Medical Error Diagnosis: Solving the Most Baffling Medical Mysteries This is Going to Hurt: Secret Diaries of a Young Doctor Swallow: Foreign Bodies, Their Ingestion, Inspiration, and the Curious Doctor Who Extracted Them Expert: Understanding the Path to Mastery Women in White Coats: How the First Women Doctors Changed the World of Medicine You Bet Your Life: From Blood Transfusions to Mass Vaccination, the Long and Risky History of Medical Innovation Attending: Medicine, Mindfulness, and Humanity Psychology: Individual How We Decide Algorithms to Live By: The Computer Science of Human Decisions How Not to Be Wrong: The Power of Mathematical Thinking Amazing Decisions: The Illustrated Guide to Improving Business Deals and Family Meals The Logic of Failure: Recognizing and Avoiding Error in Complex Situations Sway: The Irresistible Pull of Irrational Behavior Anatomy of a Secret Life: The Psychology of Living a Lie The Secret Life of the Mind: How Your Brain Thinks, Feels, and Decides Gut Feelings: The Intelligence of the Unconscious Superminds: The Surprising Power of People and Computers Thinking Together Incognito: The Secret Lives of the Brain The Paradox of Choice: Why More Is Less The Forgetting Machine: Memory, Perception, and the Jennifer Aniston Neuron Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones How Emotions Are Made: The Secret Life of the Brain Psychology: Interacting with Others The Stuff of Thought: Language as a Window into Human Nature Invisible Women: Data Bias in a World Designed for Men Shape: The Hidden Geometry of Information, Biology, Strategy, Democracy, and Everything Else Rock Breaks Scissors: A Practical Guide to Outguessing and Outwitting Almost Everybody The Confidence Game: Why We Fall for It . . . Every Time Reading People: How Seeing the World through the Lens of Personality Changes Everything The Wisest One in the Room: How You Can Benefit from Social Psychology's Most Powerful Insights Connected: The Surprising Power of Our Social Networks and How They Shape Our Lives The Lucifer Effect: Understanding How Good People Turn Evil Flash Boys: A Wall Street Revolt The Bed of Procrustes: Philosophical and Practical Aphorisms / Nassim Nicholas Taleb Expert Political Judgment: How Good Is It? How Can We Know? / Philip Tetlock Unmaking the West: "What-If?" Scenarios That Rewrite World History / Philip Tetlock Counterfactual Thought Experiments in World Politics: Logical, Methodological, and Psychological Perspectives / Philip Tetlock Biography Furiously Happy: A Funny Book About Horrible Things Broken (In the Best Possible Way) Self-Help Tiny Beautiful Things: Advice from Dear Sugar Crime The Casebook of Forensic Detection: How Science Solved 100 of the World's Most Baffling Crimes Books I've Read: Fiction Series Millennium : The Girl with the Dragon Tattoo, The Girl Who Played with Fire, The Girl Who Kicked the Hornet's Nest, The Girl in the Spiders Web, The Girl who takes an Eye for an Eye, The Girl Who Lived Twice Penumbra : Mr. Penumbra's 24-Hour Bookstore and Ajax Penumbra 1969 Don Tillman : The Rosie Project (#1), The Rosie Effect (#2) Harold Fry : The Unlikely Pilgrimage of Harold Fry (#1) Olive Kitteridge : Olive Kitteridge (#1) The Hundred-Year-Old Man : The 100-Year-Old Man Who Climbed out the Window and Disappeared (#1) Historical Fiction Nora Beady : The Girl in His Shadow (#1) and The Surgeons Daughter (#2) Kate Quinn: The Alice Network , The Rose Code Ann Leary: The Foundling All the Light We Cannot See The Kitchen Front Code Name Hélène The Dictionary of Lost Words The Lost Apothecary The Miniaturist The Book of Speculation Crime/ Mystery Paula Hawkins Collection: The Girl on the Train , A Slow Fire Burning Liane Moriarty Collection: Nine Perfect Strangers , Apples Never Fall Lucy Foley Collection: The Guest List , The Paris Apartment (read first half) The Witch Elm Sometimes I Lie Before the Fall The Lovely Bones Burglars Can't Be Choosers The 7 1/2 Deaths of Evelyn Hardcastle Wrong Place, Wrong Time The House in the Pines The Golden Spoon Killers of a Certain Age The Bequest The Lifeguards The Truth about the Harry Quebert Affair The Truth and Other Lies The Finishing School Crime/ Mystery: Series Three Pines (Chief Inspector Gamache) : Still Life (#1), A Fatal Grace (#2), The Cruelest Month (#3), A Rule Against Murder (#4), The Brutal Telling (#5), Bury Your Dead (#6), A Trick of the Light (#7), The Beautiful Mystery (#8), How the Light Gets In (#9), The Long Way Home (#10), The Nature of the Beast (#11), A Great Reckoning (#12), Glass Houses (#13), Kingdom of the Blind (#14), A Better Man (#15), and All the Devils are Here (#16) Cormoran Strike : Cuckoo's Calling (#1), The Silkworm (#2), Career of Evil (#3), Lethal White (#4), Troubled Blood (#5), The Ink Black Heart (#6), and The Running Grave (#7) Thomas De Quincey : Murder as a Fine Art (#1) Dublin Murder Squad : In the Woods (#1), The Likeness (#2), Faithful Place (#3), Broken Harbor (#4), The Secret Place (#5), and The Trespasser (#6) Hawthorne and Horowitz : The Word is Murder (#1), The Sentence is Death (#2), A Line to Kill (#3), and The Twist of a Knife (#4) Susan Ryeland : Magpie Murders (#1) and Moonflower Murders (#2) Sam Clair : A Murder of Magpies (#1) and A Bed of Scorpions (#2) Quantico Files : Night Fall (#1), Dead Fall (#2), and Free Fall (#3) Kaely Quinn Profiler : Mind Games (#1) Jack Reacher : The Killing Floor (#1) and Die Trying (#2) Charles Lenox Mysteries : A Beautiful Blue Death (#1), The September Society (#2), The Fleet Street Murders (#3), A Stranger in Mayfair (#4), A Burial at Sea (#5), A Death in the Small Hours (#6), An Old Betrayal (#7), and The Laws of Murder (#8) Thursday Murder Club : Thursday Murder Club (#1), The Man Who Died Twice (#2), The Bullet That Missed (#3) Nell Ward Mysteries : A Murder of Crows (#1), A Cast of Falcons (#2), A Mischief of Rats (#3), A Generation of Vipers (#4), and A Traces of Hares (#5) Molly the Maid : The Maid (#1) and The Mystery Guest (#2) Cal Hooper : The Searcher (#1) Dr. Thomas Silkstone : The Anatomist’s Apprentice (#1) The Checquy Files : The Rook (#1) Letty Davenport : The Investigator (#1) The Marlow Murder Club : The Marlow Murder Club (#1) and Death Comes to Marlow (#2) Inspector Ian Rutledge : A Test of Wills (#1) Detective Varg : The Department of Sensitive Crimes (#1) Science Fiction/ Fantasy Matt Haig: The Midnight Library , How to Stop Time Neil Gaiman: Neverwhere , Stardust , Trigger Warning: Short Fictions and Disturbances Emily St. John Mandel: Station Eleven , Sea of Tranquility , The Glass Hotel A Wrinkle in Time Hitchhikers Guide to the Galaxy The Coincidence Makers The Invisible Life of Addie LaRue Spoonbenders The Impossible Lives of Greta Wells The First 15 Lives of Harry August The Alchemist Other Birds Good Morning, Midnight Science Fiction/ Fantasy: Series Maze Runner : The Maze Runner (#1), The Scorch Trials (#2), The Death Cure (#3), The Kill Order (#4), and The Fever Code (#5) Divergent : Divergent (#1), Insurgent (#2), Allegiant (#3), and Four (#4) Red Queen : Red Queen (#1), Glass Sword (#2), and King's Cage (#3) Southern Reach : Annihilation (#1), Authority (#2), and Acceptance (#3) Shades of Magic (VE Schwab): A Darker Shade of Magic (#1) Caraval : Caraval (#1), Legendary (#2), Finale (#3) Mither Mages (Orson Scott Card): The Lost Gate (#1), The Gate Thief (#2), and The Gatefather (#3) The Mortality Doctrine : The Eye of Minds (#1) Wayward Children : Every Heart a Doorway (#1) Romance/ Chick Lit The Bookish Life of Nina Hall : The Bookish Life of Nina Hall (#2), Adult Assembly Required (#2) Katherine Center: Things you save in a Fire , What You Wish For , The Bodyguard The Art of Hearing Heartbeats Lessons in Chemistry The Queen of Hearts Oh Dear Silvia Ghosted The Overdue Life of Amy Byler My (not so) Perfect Life Foreign Affairs Humor Eleanor Oliphant is Completely Fine Nothing to See Here Novels Phaedra Patrick Collection: The Curious Charms of Arthur Pepper , The Messy Lives of Book People , The Library of Lost and Found , The Secrets of Love Story Bridge Jodi Picoult Collection: Wish You Were Here , The Book of Two Ways Tomorrow, and Tomorrow, and Tomorrow A Week in Winter Seven Days of Us I Miss You When I Blink Ella Minnow Pea The Keeper of Lost Things Gravity is the Thing The School for Good Mothers Something to Live For (Previously: How not to die alone) Anxious People The Gifted School Wicked Leaks A Thousand Pardons The Department of Rare Books and Special Collections Remarkably Bright Creatures The Chemist Books I've Read: Non-Fiction Medical When Breath Becomes Air How Doctors Think Cheating Death: The Doctors and Medical Miracles that Are Saving Lives Against All Odds Stiff: The Curious Lives of Human Cadavers The Naked Lady Who Stood on Her Head: A Psychiatrist's Stories of His Most Bizarre Cases Admissions: Life as a Brain Surgeon Patient H.M.: A Story of Memory, Madness, and Family Secrets Under the Knife: A History of Surgery in 28 Remarkable Operations Medical: By Atul Gawande Being Mortal: Medicine and What Matters in the End Checklist Manifesto: How to Get Things Right Better: A Surgeon's Note on Performance Complications: A Surgeons Notes on an Imperfect Science Under the Knife: A History of Surgery in 28 Remarkable Operations Crime Never Sucks a Dead Man's Hand: Curious Adventures of a CSI Climbing Adventures Into Thin Air: A Personal Account of the Mt. Everest Disaster Biography Unbroken: A World War II Story of Survival, Resilience, and Redemption Scrappy Little Nobody: Anna Kendrick Bossypants: Tina Fey Maybe You Should Talk to Someone: A Therapist, HER Therapist, and Our Lives Revealed Let’s Pretend This Never Happened: A Mostly True Memoir Social Psychology Leonard Mlodinow: The Drunkards Walk: How Randomness Rules our Lives and Elastic: Unlocking Your Brain's Ability to Embrace Change Daniel Kahneman: Thinking, Fast and Slow and Noise: A Flaw in Human Judgment Scienceblind: Why Our Intuitive Theories About the World Are So Often Wrong Contagious: Why Things Catch On Made to Stick: Why Some Ideas Survive and Others Die A Field Guide to Lies: Critical Thinking in the Information Age Loonshots: How to Nurture the Crazy Ideas That Win Wars, Cure Diseases, and Transform Industries When: The Scientific Secrets of Perfect Timing You Are Not So Smart Behave: The Biology of Humans at Our Best and Worst Grit: The Power of Passion and Perseverance Range: Why Generalists Triumph in a Specialized World Originals: How Non-Conformists Move the World Everybody Lies: Big Data, New Data, and What the Internet Can Tell Us About Who We Really Are Everything is Obvious: Once You Know the Answer The Disappearing Spoon: And Other True Tales of Madness, Love, and the History of the World from the Periodic Table of the Elements Freakanomics: A Rogue Economist Explores the Hidden Side of Everything Farsighted: How We Make the Decisions That Matter the Most Superforecasting: The Art and Science of Prediction Barking up the Wrong Tree: The Surprising Science behind why everything you know about success is [mostly] wrong Quirky: The Remarkable Story of the Traits, Foibles, and Genius of Breakthrough Innovators Who Changed the World Start with Why: How Great Leaders Inspire Everyone to Take Action Team of Teams: New Rules of Engagement for a Complex World The Knowledge Illusion: Why we never think alone The Signal and the Noise: Why So Many Predictions Fail--but Some Don't The Basic Laws of Human Stupidity Incerto/ Nassim Nicholas Taleb : Skin in the Game: Hidden Asymmetries in Daily Life, Fooled by Randomness: The Hidden Role of Chance in Life and in the Markets and Black Swan: The Impact of the Highly Improbable Social Psychology: By Malcolm Gladwell Outliers: The Story of Success The Tipping Point: How Little Things Can Make a Big Difference Blink: The Power of Thinking without Thinking David and Goliath: Underdogs, Misfits, and the Art of Battling Giants Where to get books Check out your local library- many have accounts with online resources, including e-books, audiobooks, etc. Library card required. Overdrive. Access to electronic books and audiobooks from your local library. Audible. $7.95 or 14.95/ month (1-month free trial). Likewise. Find new books, movies, and TV shows based on your favorites. *Follow me to check out my list of recommendations* What Should I Read Next? Enter a book you enjoyed or a favorite author, and find recommendations for other books. Military? You can access magazines, books, videos, newspapers, audiobooks, and random other stuff. First, you need to get an account with an MWR Library. Navigate from the website designated from the MWR resource page, and then save the link for the websites (can't use the generic RBDigital and Overdrive websites). Establish an account and enjoy exploring! MWR Library Resources Online Resources. List of resources- RBDigital, Overdrive, Mango Language service, etc. RBDigital Magazines, e-books, audiobooks, video Overdrive E-books, audiobooks, and videos Mango Language Services. 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< Back Acute Care Surgery Clinical Guidelines EAST Practice Management Guidelines. Evidence-based guidelines developed and published by EAST. Covers EGS, ICU, trauma, and injury prevention. SurgicalCriticalCare.Net . Evidence-based guidelines from Orlando Regional Medical Center. Vanderbilt Trauma and Surgical Critical Care Practice Management Guidelines. Evidence-based guidelines developed by Vanderbilt. Covers trauma and surgical critical care topics. Evidence-Based Decisions in Surgery. This does require membership with the American College of Surgeons. General Medical Information UpToDate. The name says it all- evidence-based recommendations based on the most current literature. Subscription required. Previous Next

< Back Delirium...what's going on? A 29-year-old male with moderate traumatic brain injury (TBI) remains intubated in the surgical ICU (SICU) due to agitation/ delirium during daily spontaneous awakening and breathing trials (SAT/ SBT). What are the clinical priorities? Rule out acute processes that can cause agitation and delirium, such as anemia, acidosis, hypoxemia, infection, intra-cranial process, fever, and an adverse drug reaction. Other potential causes? Immobility, "lines and tubes." Isolation, disorientation, lack of normal sleep-wake patterns Endocrine or metabolic derangements Organ dysfunction (renal disease, liver disease, etc) Withdrawal from chronic home medications (benzodiazepines, alcohol, psychiatric medication, etc.). What are the treatment principles for agitation and delirium? Treat organic reversible causes (treat infection, minimize unnecessary medication, etc.) Implement non-pharmacology therapy (sleep-wake cycles, lights and stimulation during the day and darkness at night) Pharmacologic agents can be used once reversible causes are remedied and non-pharmacologic therapy has been instituted. After the optimization of non-pharmacologic therapy, the patient was successfully extubated. A few days later on rounds, the patient was sitting up in bed. During our conversation, I noticed that he was drinking a Mountain Dew. His mom told us that he drinks multiple Mountain Dews every day (read- 6 or more). I told her that I suspect this had a significant role in his altered mental status during attempts at ventilator liberation. Management of Agitation and Delirium Definition Agitation is a psychomotor disturbance characterized by excessive motor activity and a feeling of “inner tension”. Delirium is an altered consciousness with reduced focus/ cognitive function. It is abrupt in onset and can have a fluctuating presentation. High prevelance, often misdiagnosed. Classified as hypoactive (most common, worse prognosis, difficult to diagnose), hyperactive (better prognosis) or mixed. Etiologies Acute illness- sepsis , electrolyte/ metabolism disorders, hyperthermia, hypoxia, hypotension, EtOH withdrawal, organ dysfunction, polytrauma, emergency surgery Patient factors- elderly, history of depression/ stroke/ dementia, history of EtOH abuse, tobacco use. Hearing or vision impairment. Iatrogenic- noise, discomfort, pain, sedative/ analgesics, ventilator dyssynchrony. Exacerbated by pain, anxiety, discomfort. Diagnosis [see charts below] Assess consciousness with Richmond Agitation-Sedation Scale (RASS). 10 point scale, ranging from combative to unarousable. Assess for delirium with Confusion Assessment Method for the ICU (CAM-ICU). 1-2 min test, 98% accurate in diagnosing delirium. Assess over 24 hrs to capture nocturnal symptoms. Non-Pharmacologic Treatment of Delirium Diagnose and manage underlying acute illness - Treat sepsis as appropriate- antibiotics, source control, etc. - Correct hypoxia, metabolic disturbances, dehydration, hyperthermia Non-pharmacologic interventions for anxiety/ discomfort[1] Periodic reorientation and reassurance from nursing staff Cognitive stimulation Correction of sensory deficits Management of environment (reassess need for invasive devices) Normalize sleep/wake cycles Minimize iatrogenic factors (sedation) Pharmacologic Therapy for Delirium Typical anti-psychotic- Haloperidol. MIND and HOPE-ICU trial- no difference in duration of delirium.[2,3] AID-ICU trial- no difference in mortality.[4] Atypical anti-psychotic- Quetiapine, Ziprasidone MIND-USA trial- no difference in delirium duration with either agent [5] Dexmedetomidine MENDS and SEDCOM trials- ↓ mechanical ventilation and ↓ delirium vs benzos [6,7] MIDEX and Prodex trial- non-inferior compared to benzos/ Propofol [8] DahLIA trial- quicker and more sustained resolution of delirium vs placebo [9] SPICE III Trial- similar mortality and similar number of delirium-free days [10] MENDS II Trial- similar number of delirium-free days vs Propofol.[11] Melatonin Pro-MEDIC Trial- prophylactic melatonin didn't decrease delirium prevalence[12] Assessment for Caffeine Withdrawal Obtaining a detailed patient history, or even a focused history of the most pertinent diagnoses or medication (blood thinners, cardiac disease) is often challenging in traumatically injured parents who may have decreased mental status due to injury or intoxication. Documenting daily caffeine intake is not typically a key component in a surgical history. However, caffeine is readily available and is the most commonly used drug in the world.[13] Unfortunately, it has significant systemic effects. Along with nicotine, it is gaining more attention as a potential etiology of altered mental status or other symptoms that would typically prompt extensive work-up. If a patient has persistent altered mental status after evaluating typical causes, consider the possibility that the patient could be missing their usual caffeine fix. "Withdrawal symptoms caused by people abruptly stopping smoking or drinking tea and coffee can include nausea, vomiting, headaches, and delirium and can last for up to two weeks."[14] References Faustino TN et al. Effectiveness of combined non-pharmacological interventions in the prevention of delirium in critically ill patients: A randomized clinical trial. J Crit Care. 2022;68:114-120. MIND Trial. Girard TD et al. Feasibility, efficacy, and safety of antipsychotics for intensive care unit delirium: The MIND randomized, placebo-controlled trial. Crit Care Med. 2010;38(2):428-437. HOPE-ICU Trial. Page VJ et al. Effect of intravenous haloperidol on the duration of delirium and coma in critically ill patients (Hope-ICU): a randomised, double-blind, placebo-controlled trial. Lancet Resp Med. 2013;1(7):515-523. AID-ICU Trial. Andersen-Ranberg NC et al. Haloperidol for the Treatment of Delirium in ICU Patients. N Engl J Med. Published online October 26, 2022. MIND-USA Trial. Girard TD et al. Haloperidol and Ziprasidone for Treatment of Delirium in Critical Illness. N Engl J Med. 2018;379(26):2506-2516. MENDS Trial. Hughes CG et al. Dexmedetomidine or Propofol for Sedation in Mechanically Ventilated Adults with Sepsis. N Engl J Med. 2021;384(15):1424-1436. SEDCOM Trial. Riker RR et al. Dexmedetomidine vs Midazolam for Sedation of Critically Ill Patients: A Randomized Trial. JAMA. 2009;301(5):489. MIDEX and PRODEX Trials. Jakob SM et al. Dexmedetomidine vs Midazolam or Propofol for Sedation During Prolonged Mechanical Ventilation: Two Randomized Controlled Trials. JAMA. 2012;307(11):1151. DahLIA Trial. Reade MC et al. Effect of Dexmedetomidine Added to Standard Care on Ventilator-Free Time in Patients With Agitated Delirium: A Randomized Clinical Trial. JAMA. 2016;315(14):1460. SPICE III Trial. Shehabi Y et al. Early Sedation with Dexmedetomidine in Critically Ill Patients. N Engl J Med. 2019;380(26):2506-2517. MENDS II Trial. Hughes CG et al. Dexmedetomidine or Propofol for Sedation in Mechanically Ventilated Adults with Sepsis. N Engl J Med. 2021;384(15):1424-1436. Pro-MEDIC Trial. Wibrow B et al. Prophylactic melatonin for delirium in intensive care (Pro-MEDIC): a randomized controlled trial. Intensive Care Med. 2022;48(4):414-425. Caffeine: The chemistry behind the world’s most popular drug Stephenson J. Nicotine and caffeine withdrawal may affect ICU patients. Nursing Times. June 2019 . RASS for Agitation Assessment CAM-ICU For Delirium Assessment Previous Next

Comfortably Numb < Back Maintaining our humanity in the clinical environment If you are working in an intensive care unit, your patients will frequently be intubated and/ or sedated. The ICU can be very dehumanizing, and it is easy to forget that patients are human beings with family and friends that love them. Adherence to critical care guidelines and following protocols is important. But while we are providing the highest level of care based on evidence, we must not ignore the humanity of our patients. There is a missing link that isn’t routinely taught in school or nurtured in training and isn’t encouraged when it is performed. The human connection, treating a patient like a person. Treat your patients as if they were your family member. Basic human decency supports the practice of avoiding derogatory conversations in the presence of patients. I have witnessed more than a handful of incidents of medical personnel discussing other patient scenarios in the presence of other patients. HIPAA laws aside, generic simple conversations are likely unavoidable (“hey the patient next door needs his pain medication…”, “is room 7 ready for radiology…”, etc). However, I have witnessed providers speaking about a brain dead patient who was being evaluated for organ donation in the presence of another patient. Speaking about death and organ donation in the room of a critically ill patient is unacceptable. Mentioning derogatory things about patients in the operating room is unacceptable. My personal opinion is that negative things should be avoided in general. I don’t mean that real problems should be swept under the rug. But in my opinion, extraneous negative remarks have no place in a patient's room. A few thoughts. 1. Don’t lose your humanity. Treat all patients as if they were your loved one (family, friend, whatever fits that category for you). If you catch yourself slipping into a routine of just seeing the procedures and diagnoses, I urge you to engage in intentional self-reflection. 2. Treat all patients as if they can hear and sense everything. I am not a proponent of the occult or the metaphysical, and I don’t believe in jinxes- I don’t believe that mentioning bad prognoses makes them more likely to occur. However, I believe that most patients who are intubated and sedated are aware, on some level, of their surroundings. There are plenty of reports of patients recalling stressful experiences from their time in the ICU. I don’t think we will ever know what they can hear or sense, or how it impacts their emotional and physical well-being. Therefore, I strongly advocate for treating all patients as if they can hear and sense everything. 3. Try to imagine what you would want if you were in the patient's position. Imagine you can’t talk, you’re in pain, you have an itch you can’t scratch, your eyes are stuck shut from eye crust that you can’t wipe away, your mouth and throat feel like sandpaper, you don’t have your glasses or your hearing aids, you have no idea where you are or what day it is, etc etc. Now imagine you are slowly waking up as your sedation medicine wears off. You have people pinching you and yelling at you to open your eyes. Compare that to hearing a calm steady voice in your ear, speaking encouraging words, explaining that you are in an ICU, you have a breathing tube in place, you’re safe, your medical team is waking you up to see if you can breathe on your own and get the tube out. I’m not suggesting that this practice will eliminate agitation when a spontaneous awakening trial is performed. But just imagine the difference of being reoriented when you have no control instead of being shouted at and told to open your eyes. Imagine someone taking a wet washcloth to your eyes to remove the crust, allowing you to open your eyes for the first time in days. It’s not something you’ll learn in medical school. And it shouldn’t be revolutionary…but just imagine the difference in the patient's perspective and understanding of their situation. Previous Next

< Back Getting Involved Getting involved in your training program and hospital is crucial for your professional development and growth. Here are some tips to help you get started. - Be open to opportunities to get involved early and embrace small projects. Even if a project seems insignificant, it can lead to bigger opportunities. Don't hesitate to accept requests to help write a paper, design a research protocol, or participate in a committee. These small projects can open doors for more significant roles and responsibilities in the future. - Be proactive and take the initiative to get involved. Talk to your mentors and program directors about your interest in participating in projects or committees. Ask for guidance on how to get involved, and don't be afraid to express your interest in specific areas. - Get involved in research. You don’t have to have a strong research background to contribute to ongoing projects. If you have specific research interests, seek the advice of someone with a similar interest and collaborate with them. Different faculty members will have their individual strengths and passions, which are frequently apparent after you interact with them. If you partner up with someone who has a similar interest, they will be able to guide you and lend their support to your project. Training programs frequently have requirements for research and have a framework for supporting involvement in ongoing projects. Research requirements are often a part of training programs, so take advantage of the support and resources available to you. Also, keep in mind that there may be ongoing research projects at your hospital that you can contribute to. - Attend department and hospital level conferences. Grand rounds, morbidity and mortality (M&M) and case conferences are invaluable learning opportunities. Conferences that review complications or deaths are invaluable learning opportunities. They are also a good platform for developing performance improvement projects. Many patient incidents are multifactorial, and there are frequently systems issues that can be addressed to minimize repeat events. - Join committees. Committees are a great way to learn about the inner workings of the hospital and contribute to important decision-making processes. They also provide a venue to meet colleagues in other departments and gain valuable networking experience. - Talk to people. Reach out to your mentors, program directors, and research staff about other opportunities that may be available. They can often provide valuable insight and connections that can lead to new opportunities and projects. After you have explored the opportunities to get involved in your program and hospital, it’s time to widen your professional network. Expanding beyond your hospital will help you stay current with industry trends, discover new opportunities, and establish relationships with colleagues and mentors. One way to do this is by participating in surgical organizations at the national level. Here are some examples: - American College of Surgeons (ACS). The ACS offers membership and participation opportunities starting in medical school. As a member, you can take advantage of educational programs, networking events, and leadership development opportunities. Fellowship in the ACS (FACS) requires board certification, and it is a prestigious recognition that can enhance your professional reputation. - American Association for the Surgery of Trauma (AAST). AAST is the premier national organization for the field of acute care surgery (trauma, surgical critical care and emergency general surgery). There are numerous opportunities for involvement in research and professional development. Membership requires FACS status. However, the organization recently added an associate membership category, which offers younger surgeons an opportunity to participate in the AAST's activities and programs. - The Eastern Association for the Surgery of Trauma (EAST). EAST provides leadership and development opportunities for young surgeons who are actively involved in the care of injured patients. The organization offers ample opportunities to get involved in committees, research projects, mentorship, and leadership roles. This is far from an exhaustive list, but it is a good starting point for young surgeons to explore how they want to develop their network. During my Acute Care Surgery fellowship, I was able to get involved in various research projects and initiatives that allowed me to further develop my expertise and knowledge in the field. At the start of my fellowship, I developed a research protocol that evaluated the impact of legislation on the opiate epidemic. This project allowed me to delve into a critical issue facing the healthcare industry and explore potential solutions to mitigate the epidemic's impact. Shortly after, I attended a department committee that updated our clinical practice guidelines. As we discussed some recent patients with rib fractures, I saw the importance of updating our thoracic trauma management guidelines. I partnered with one of the faculty who had a particular focus on rib fracture management and we worked to optimize our protocol for caring for these patients. This led to multiple opportunities, including an IRB protocol and two manuscript submissions on operative rib fixation. I also had the opportunity to co-author a book chapter on Intensive Care Unit (ICU) management of blunt chest trauma and a manuscript on the use of opiates in chest trauma. During a meeting with one of the research directors in our department, I was able to learn about opportunities to get involved in ongoing projects. This led to me joining a group working on coagulopathy in traumatic brain injury. Through this project, I was able to contribute to a literature review submission and co-author a research manuscript submission. I was also able to present our findings at a national conference. My program director was a strong supporter of and actively shared news about opportunities that could further my career development. One of these opportunities included writing an essay that allowed me to publish and present at a conference. After reading my essay, a critical care physician reached out to connect and invited me to participate in testing a tool for resuscitation in austere environments. This was a unique opportunity that allowed me to apply my knowledge and skills in a new and challenging setting. Overall, my Acute Care Surgery fellowship allowed me to explore different avenues in research and develop expertise in areas that I am passionate about. It also enabled me to collaborate with other experts in the field, broaden my network, and gain invaluable experiences that served me well in my future career endeavors. Previous Next

Welcome to Doc on the Run! A look into the life and mind of an Acute Care Surgeon ​ Sharing the knowledge and wisdom gained after 38 years of life (and over 20 years in medicine). ​ For those who want to learn about the specialty of Acute Care Surgery , you will find insight into the profession, both from personal experiences and citations from articles and websites. For those interested in the medical profession, particularly surgery, you will find career management tips , including networking and mentorship . For learners (students, residents, fellows), you will discover a wide array of educational resources, including recommended educational resources , tutorials on a multitude of topics, a collection of didactic lectures and quick reference guides , an ever-growing library of literature reviews , and clinical vignettes . For fellow Acute Care Surgeons, please consider collaborating and sharing your experience and wisdom with the next generation. For the bibliophiles, check out the constantly expanding list of book recommendations .

When The Scientific Secrets of Perfect Timing - We should capitalize on our natural circadian rhythms. What is your chronotype? - Premortem. Examine what you think could go wrong. Not getting a book written. Think of what could cause it. Not writing every day. Not keeping the editor updated. Think of how to change those to positive actions. He wrote six days a week and consulted his editor regularly. - Techniques for promoting belonging in your group? Email response time is the single best predictor of whether employees are satisfied with their boss. - Syncing to the heart- working in harmony with others makes it more likely we will do good. Previous Next

< Back Organizational Hacks How not to lose everything All my life, I've been forgetful and easily distractible. I joke that I'd lose my head if it wasn't attached. This challenge is part of my ADHD, and I can't overcome it with sheer willpower. The list of things that I've lost over the years is staggering- homework (oh so much homework…it was usually stuffed somewhere in my locker), clothing, books, charging cables, water bottles, earrings (what am I supposed to do with the remaining single earrings?) and a white polar bear stuffed animal (he was left in a hotel room on a road trip as a child). I'm looking forward to learning where all my things went when I die and go to heaven. So if this can’t be overcome with sheer willpower, how can you adapt? Check out these techniques or tools to see if you find something that would be useful for yourself. Information * Create a tool for yourself for storing the data you need to be able to access reliably. This website is full of high-yield medical information that is rapidly accessible, but a website is a labor-intensive option. You don’t have to invest time and money into a website. Here are some other options (check out this post for more details ): - Invest in a planner . Electronic options that sync are useful because they minimize the need to re-write things in multiple places. Another option that I prefer is one notebook that keeps all my events in one place, along with my collection of lists and reminders. - Write everything down. My planner is my note repository. The Apple Notes application is also useful because it can sync across multiple Apple devices. At home or work, dry-erase poster paper can be used to take notes, keep track of schedules and provide reminders for long-term tasks and due dates. - Trello is a user-friendly free application with multiple functions, including the creation of lists, storage of documents, and the ability to share notes or documents among team members/ family members. Items * Magnet strips . Using magnetic sheets the size of business cards, cut pieces and strips to put on various items and stick them to the fridge or other magnetic surface of your choice. For example, if you use dry-erase poster paper on the refrigerator, thin strips of magnet can be cut to fit along the length of several dry eraser markers, so they're always on hand when you have something to jot on the whiteboard * Keys on a hook by the front door. 3M hooks work well, but the hook design isn’t as important as placement, ideally not in direct sight of the door. You can also hang your work ID badge or any other small items you need when you leave the house. * Keep track of all your cords with these tie wraps . Inexpensive and sturdy. I didn’t think there was any way I’d use 50- I figured maybe a couple, just for a handful of my charging cables that always end up in a jumble. But trust me, you'll find plenty of uses for them! Finances and Important Documents * Save receipts for anything valuable. If it was purchased online, download the digital receipt. Use the "Create PDF" function to combine receipts. For paper receipts, an envelope in a drawer is a simple option. Every so often, review the receipts, and if there is anything you don't need anymore, toss it. * Paper shredder . Anything with personal information should be destroyed before being thrown away. This is technically not about avoiding losing something, but it’s an important task so it is included here. * Taxes. Instead of waiting until tax season, keep track of key documents and expenses throughout the year. A running spreadsheet of business expenses, donations, etc, can avoid the frantic search in March. * Metal rack of hanging file folders. Each folder has a different label, including taxes (donation receipts, investment statements, etc), moves (signed leases, welcome packet with key information, etc), and business (bank paperwork, original EIN and registration forms, deposited checks). Previous Next

About Doc on the Run Active Duty Army Acute Care Surgeon. Nomad. Runner. Music aficionado. Culinary amateur. Intermediate-level technology nerd. Christian. Inquisitive life-long learner. ​ My primary passion is surgery, and my life has been dedicated to becoming a trauma surgeon. After graduating high school at 17, I attended the University of Missouri, Kansas City, a six-year medical school. I was commissioned in the Army and completed 6 years of General Surgery residency in Augusta, Georgia. Board-certified in General Surgery. For 3 years, I was a staff General Surgeon in North Carolina and deployed to Iraq, Kuwait, Jordan, and Africa. Board-certified in Surgical Critical Care and completed a two-year AAST Acute Care Surgery fellowship in North Carolina. I spent two years in San Antonio, Texas, and then 1 year in South Korea, where I finished out my career on Active Duty. Photo courtesy of JW, 2013

Made to Stick Why Some Ideas Survive and Others Die 6 Principles of Sticky Ideas - Simple - Unexpected- crash at the end of the car commercial. - Concrete - Credibility- the ability to test. Before you vote ask yourself if you are better off today than you were 4 years ago- Reagan. - Emotions - Stories Curse of knowledge- we find it hard to imagine not knowing what we have learned. Can’t imagine what it’s like not to understand a certain concept that we accept as fact Previous Next

< Back Blast- Multiple Penetrating Injuries A 32-year-old male soldier sustained a severe blast injury with a chest wound and a supraclavicular wound, a tangential right shoulder wound, and right hand wounds. He arrives at the hospital for care. He was awake and alert, hemodynamically normal. A secondary survey revealed these wounds. Injury Pattern What are the possible injuries based on this wounding pattern? Intra-thoracic (cardiac, pulmonary), great vessels/ right subclavian vessels Next steps in evaluation? Extended FAST exam to evaluate for fluid in chest, abdomen, and pericardial space. CXR to identify for retained foreign body. Helpful to place radio-opaque markers on wounds to help establish trajectory. Plain film of chest/ upper abdomen What additional injuries are possible based on these wounds and imaging? Any organ in the path of the wounds can be injured- this includes intra-abdominal structures (small and large bowel, stomach, spleen, kidney), retroperitoneal structures (kidney) and the diaphragm. How do we determine which body cavity to explore first? Hemodynamic stability and wounding pattern can direct how to proceed. A hemodynamically unstable patient requires swift intervention concurrent with ongoing resuscitation, while a stable patient can be approached more deliberately. The clinical exam can suggest which body cavity is causing the instability. Peritonitis, abdominal distension, grossly positive FAST in the abdominal views suggest the abdomen as the site of injury. Signs of thoracic injury causing instability include decreased breath sounds, jugular vein distension, muffled heart sounds, fluid on pericardial view of the FAST fluid, and a large volume of bloody output in the chest tube. In addition, location of projectiles on plain film help determine trajectory, and any structures along the trajectory can be injured. This patient was managed in a deployed environment by an austere surgical team. We did not have access to CT imaging and we had limited capacity for continuous monitoring. Therefore, in order to rule-out cardiac and intra-abdominal injuries, we performed a midline laparotomy. We performed a pericardial window through the laparotomy. There was no fluid in the pericardium. We performed an abdominal exploration. There were no intra-abdominal injuries. Wounds in the Cardiac Box In the classic description, the “cardiac box” is bordered superiorly and inferiorly by the sternal notch and the xiphoid process, and laterally by the nipples. However, thoracic gunshot wounds outside these confines can just as readily result in a cardiac injury. The diagnosis of cardiac injuries starts with a physical exam and FAST. Physical exam findings can include hemodynamic instability, muffled heart sounds, and jugular venous distension (Beck's triad). FAST will reveal pericardial fluid. If the patient is awake, they may be panicked and have an impending sense of doom. Penetrating cardiac injuries require operative repair. FAST Examination Online Tutorial Society for Academic Emergency Medicine SAEM FAST Exam YouTube Video Previous Next

< Back Textbooks General Surgery: Scientific Foundations Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 21st Edition, 2021. This is the detailed explanation of the science behind the practice of surgery. This is the basic science textbook I used during residency. Mulholland and Greenfield's Surgery: Scientific Principles & Practice. Previously known as "Greenfields". General Surgery: Beyond Basic Science Cameron's Current Surgical Therapy. 13th edition, 2019. Short chapters with high-yield information on every topic in General Surgery. Must-have for later in residency. Trauma Mattox Trauma. 9th edition, 2021. The trauma surgery bible. Highly recommend. Critical Care Marino ICU. 4th edition, 2013. The ICU bible. Highly recommend. Civetta, Taylor, & Kirby's Critical Care Medicine. 5th edition, 2017. A detailed explanation of physiology, diagnosis, and management. Finks Critical Care. 7th edition, 2017. Slightly less detailed than Civetta. Excellent book- not too simplistic and not painfully detailed. Evidence-Based Practice of Critical Care. 3rd edition, 2019. Reviews the literature regarding specific high yield critical care topics. Surgical Critical Care Therapy: A Clinically Oriented Practical Approach. 1st edition, 2018. Essentials of Mechanical Ventilation. 4th edition, 2018. Previous Next