Trauma References General Reference GCS .pdf Download PDF • 78KB Injury Severity Scores .pdf Download PDF • 195KB Snakebite Severity Score .pdf Download PDF • 102KB Staplers.Sutures.Mesh .pdf Download PDF • 530KB Hemostatic Agents .pdf Download PDF • 18KB TEG .pdf Download PDF • 12KB TBI Brain Injury Guidelines .pdf Download PDF • 213KB Brain Trauma Foundation .pdf Download PDF • 148KB DVT in TBI .pdf Download PDF • 137KB Spinal Cord ASIA Score .pdf Download PDF • 1.98MB

< Back Cardiac Physiology Cardiovascular Physiology Oxygen Delivery Adequate cardiovascular function is vital to maintaining perfusion to the organs and tissues in the body. Perfusion drives oxygen delivery (O2) and removal of byproducts of cell metabolism (CO2). The amount of oxygen that is delivered (DO2) is a function of cardiac output (CO; the volume of blood ejected from the heart every minute) and the arterial oxygen content (amount of oxygen in the blood). Cardiac output is determined by the volume of blood the heart pumps out into the body with each heartbeat (stroke volume, SV) and the frequency of the heartbeat (heart rate, HR). Stroke volume depends on preload (blood volume returned to the heart), contractility (effectiveness of cardiac muscle activity), and afterload (pressure in the peripheral vasculature that the heart has to overcome to eject blood). Arterial oxygen content (CaO2) is the amount of O2 in the blood that is ejected from the heart. This is determined by dissolved O2 + O2 bound to hemoglobin. Hemoglobin carries O2, and the percentage of Hgb molecules that are saturated (bound) with O2 is determined by arterial blood gas (SaO2, arterial oxygen concentration) or pulse oximetry (SpO2, peripheral arterial oxygen concentration). Pulse oximetry is non-invasive and is a reliable surrogate (as long as SaO2 >90%). The O2 carrying capacity of one gram of hemoglobin is 1.38 (this is a constant in the equation). So this is the first part of the equation: the number of hemoglobin molecules x the % of those molecules that are saturated with O2 x how much O2 saturated hemoglobin can carry . The second part of the equation is the dissolved oxygen (partial pressure of arterial oxygen, PaO2, reported as mmHg). This value is multiplied by the constant 0.003, which is the mL of O2 dissolved per mmHg plasma. This number is infinitesimally small relative to the other half of the equation and it is typically ignored when determining oxygen concentration. This means that the significant modifiable factor in CaO2 is Hgb. Oxygen has to have something to bind to (Hgb) because dissolved oxygen has minimal oxygen-carrying capacity. Oxygen delivery (DO2)= CO x CaO2 Cardiac Output (CO)= heart rate (HR) x SV Stroke volume (SV)= the volume of blood ejected from the heart each heartbeat. Arterial oxygen concentration (CaO2)= [1.38 x Hgb x SaO2] + [PaO2 x 0.003] How can oxygen delivery be increased? One of the components of the equation has to be adjusted. Increase cardiac output. Increase SV- use of an inotropic agent (* medication that increases the strength of the heart contraction), ensure adequate preload (volume resuscitation). Increase HR- use of a chronotropic agent (* medication that increases heart rate). Increase arterial oxygen content Increase blood hemoglobin concentration *See pharmacology below Oxygen Consumption Oxygen consumption (VO2) is determined by how much oxygen the peripheral tissues extract and use. It is the difference between oxygen delivery (DO2) and oxygen return(ed) (SvO2). Oxygen consumption (VO2)= DO2 - SvO2. Oxygen consumption is calculated by subtracting SvO2 or ScVO2 from the amount of oxygen delivered. Venous oxygen saturation (SvO2 or ScVO2)- concentration of oxygen in the blood returning to the heart. Measured with a central venous catheter. *See below under CV monitoring for more details. Cardiovascular Monitoring There are several techniques for monitoring cardiovascular parameters, ranging from non-invasive to maximally invasive. Non-invasive methods include telemetry, pulse oximetry, and blood pressure monitoring. The benefit of these devices is their simplicity of use and interpretation. But these are error-prone, and regarding blood pressure, it doesn't provide continuous monitoring. For more info, see lecture entitled " Hemodynamics ". Arterial lines can be placed to provide continuous cardiac monitoring. The arterial waveform can indicate specific pathology (see Edwards Quick Guide to Cardiovascular Care ). In addition, an arterial line can report stroke volume variation. Stroke volume variation (SVV) is a surrogate of arterial pressure changes with inspiration/ expiration. If the change in pressure with respiratory cycles is >10-15%, it suggests the patient is fluid responsive, meaning they are likely to improve their preload (and cardiac output and blood pressure) with IV fluid administration. Central venous catheters can be placed to deliver intravenous medication as well as provide cardiac monitoring. A central venous catheter can measure the pressure of the blood returned to the right atrium (central venous pressure, CVP), which is a crude measurement of preload and right heart function. In addition, the oxygenation of the blood returning to the right heart (from the head and upper body) is reported as Central venous oxygenation saturation (ScVO2). ScVO2 reflects the balance between oxygen delivery and consumption. Arterial lines and central venous catheters are considered "minimally invasive". A pulmonary artery (PA) catheter is the most invasive device for cardiac monitoring. Similar to a central venous catheter, a PA catheter can determine the oxygenation of the blood returning to the right heart, which is the mixed venous oxygen saturation (SvO2). However, in contrast to the central venous catheter which is located in the superior vena cava (proximal to the right atria), this device is measuring blood oxygenation in the pulmonary artery (from the right ventricle), so it accounts for the blood from the entire body (unlike the ScVO2). Cardiac Pharmacology Vasoactive medications are frequently used in the ICU for the management of shock, heart failure, and other acute pathology. There are several key receptors, and understanding the function of each receptor is the key to using these different agents correctly. Receptors * α (alpha) 1- vasoconstriction * α2- inhibit norepinephrine release from presynaptic neurons * β (beta) 1- chronotrope (↑HR), inotrope (↑Ca in cardiac myocytes ↑contractility), dromotrope (↑cardiac impulse conduction velocity) * β2- vasodilation * Dopa 1- vasodilation * Dopa 2- neurotransmitter release Pharmacologic Agent Classification Each medication has a specific physiologic effect based on its particular mechanism of action. Agents may stimulate or inhibit receptors (see above) or alter the concentration of a key substance (cAMP, calcium, potassium, nitric oxide (NO)). Previous Next

Barking Up The Wrong Tree The Surprising Science Behind Why Everything You Know About Success Is (Mostly) Wrong - Good grades in school- likely to be a "rule follower", and less likely to be innovative, think outside the box. - Introverts are more likely to be experts, extroverts tend to make more money (socializing, "networking"). We should look at "networking" as "making friends". This disputes the "nice guys finish last"... - Match your strengths/ passion/ skill to the right context. - Flattery (sucking up to the boss) can work in the short term, but in the end, when people see their colleagues/ neighbors/ etc cutting corners and reaping benefits, this leads to a general collapse into distrust and rule-breaking. - IQ only matters up to a certain point, but then it yields diminishing returns. After that, hard work is what makes the difference. - Tradeoffs- every hour that you spend working is an hour spent away from other things (family, hobbies). In this age of constant accessibility, you have to decide to leave work behind (ignore your emails when you're at your kid's ball game). - Gratitude in relationships- on their deathbed, people regret working too much and not saying thanks to the people in their life. - Some helpful things I learned...please note that tact and delivery matter and these are not appropriate in every scenario. - When someone is getting upset or frustrated and starts yelling, "Please speak more slowly, I want to help." Or try, "What would you like me to do?" - When someone is upset, validate/ name their feeling. "Sounds like you’re angry/ hurt/ frustrated." If you're wrong, give them the chance to correct you. - Gratitude to relationships. Previous Next

< Back GI Dysmotility...pending GI Dysfunction Previous Next

< Back Thai Chicken Enchiladas Ingredients 8 flour tortillas 2 cooked and shredded chicken breasts 1 Tbsp canola oil 1/2 sweet onion, chopped 1/3 C chopped/shredded carrots 1/2 C chopped/shredded cabbage (premade coleslaw mix works well) 4 garlic cloves, minced 1/2 tsp salt 1/2 tsp pepper 4 green onions, sliced 1/3 C chopped peanuts (more for garnish) 1/4 C chopped fresh cilantro (more for garnish) 2 1/2 C light coconut milk 1/3 C + 1/2 C sweet chili sauce Instructions 1. Preheat oven to 350 degrees F. 2. Heat oil in large skillet over medium heat. Add onions, cabbage, carrots, garlic and 1/4 tsp salt and stir to mix. Stir occasionally and cool until vegetables are soft (6-8 min). Add in chicken, green onions, peanuts, cilantro, remaining salt and pepper, tossing to coat, cook for 1-2 min. Add 3/4 c coconut milk and 1/3 c sweet chili sauce, mixing thoroughly to combine. Turn off heat. 3. Spray 9×13 dish with nonstick spray. Whisk together remaining coconut milk and sweet chili sauce. Pour about 1/2 C on the bottom of the dish. Slightly warm tortillas, then place a few spoonfuls of the chicken mixture in each, roll up tightly and place in the dish. Use a spoon to cover the tortillas with remaining coconut milk and chili sauce mix. 4. Bake for 20 minutes, remove and garnish with peanuts and cilantro. Spoon sauce from the bottom of the dish all over the tortillas. The vegetables cooling and softening Previous Rolled up and ready to head into the oven Final product! Next

< Back ICU Rounding: How I Do It The ICU can be intimidating. Critically ill patients are often surrounded by machines (ventilators, dialysis, etc) and IV poles, with multiple lines and catheters extending from their face, chest, abdomen, neck, and groin. A standardized approach can help the team synthesize and interpret all the subjective and objective data to establish a diagnosis and devise a treatment plan for these complex patients. Rounding in the ICU is different from rounding on floor patients. Floor patients are typically presented in a problem-based format- they are likely to have a short list of active issues being addressed, often just one diagnosis (cholecystitis, bowel obstruction, colon cancer status-post colectomy). Patients can certainly have co-morbidities, such as diabetes and hypertension, but they are usually relatively straightforward. Presentations are briefer than ICU presentations, and largely focus on the acute surgical diagnosis. Here is an example of a surgical floor patient. 32 year old female, hospital day 2 following laparotomy for small bowel obstruction. Her pain is controlled with oral analgesics with minimal prn requirements. She is hungry and passing flatus. She is using her incentive spirometry and ambulating. She has had minimal output in her nasogastric tube. Staples are intact along her midline laparotomy incision with no surrounding erythema and appropriate peri-incisional tenderness. Labs are only remarkable for some mild hypokalemia with K 3.4. She is voiding spontaneously with adequate urine output. Plan to replete potassium, remove NGT and advance diet. In contrast, ICU patients are fragile with more physiologic derangements that threaten homeostasis. Critical illness can profoundly impact multiple organ systems and the interdependence of organ systems adds another layer of complexity. Patients can be presented in a problem-based format, like floor patients, or a system-based format. There are pros and cons to each. As mentioned, a problem-based format addresses each diagnosis (for example- cholecystitis, bowel obstruction, heart failure, pneumonia, ileus). In contrast, a system-based format addresses each organ system (for example- cardiac, pulmonary, renal, neurologic). Problem-based might seem easier on first glance, but one downside in the ICU setting is the risk of overlooking organ systems without a discrete disease process. One downside of the system-based format is the categorization of one diagnosis to various organ systems. For example, ventilator-associated pneumonia is related to the pulmonary system but overlaps with infectious disease. However, the system-based format is comprehensive and thorough, which helps ensure that all physiologic processes are considered. One advantage of the system-based format is it’s adaptability to less complex patients. While it’s challenging to apply floor round formatting to the ICU setting, once you understand how to utilize the ICU system-based model, you can use it to briefly review non-ICU patients to ensure that you don’t forget something. For a young male with cholecystitis, you don’t need to report GCS, medication infusion rates, ventilator settings, insulin requirements, etc. But the systems are still pertinent- address pain (neuro), ensure normal vitals (cardiac) and use of incentive spirometer (pulmonary), check oral intake, assess return of bowel function and examine wounds (GI), inquire about adequate urination and review BMP (renal), ensure no fever, review CBC (heme and ID), and ensure ambulation/ SCDs (prophylaxis). ICU care is a team endeavor, requiring the integration of nursing, respiratory therapy (RT), dieticians, pharmacists, physical therapy and other team members to provide comprehensive care. ICUs must implement a system to integrate care plans between all team members. This can occur in different formats, either with “prerounds” (brief discussion with multidisciplinary team about each patient before formal rounds) or with multidisciplinary rounds (team members present their key data points/ plans in a structured format). One example of multi-disciplinary rounds (abbreviated): resident reports one-liner (see example below); nurse reports their assessments (pain/ sedation scores, delirium assessment, etc); RT reports current ventilator settings, results of spontaneous breathing trials and respiratory treatments; the resident then presents the patient as below. Order of Presentation during Rounds 1. Brief one-liner [presented by the resident, APP or student caring for the patient]. See below. 2. Bedside nurse- report on sedation, pain, infusion rates, etc 3. Respiratory therapy- report on ventilator settings, respiratory interventions, etc 4. Formal patient presentation [presented by the resident, APP or student caring for the patient]. See below. 5. Pharmacist- review of medications, including potential dose adjustments, antibiotic tailoring, etc 6. Attending 7. FAST-HUG- ensure that key aspects of care are addressed (feeding, analgesia, sedation, thromboprophylaxis, head of bed elevated, ulcer prophylaxis, glycemic control) 8. Readback- nurse briefly summarizes the key goals of the day One-liner: brief patient history, acute overnight events. Example: 32 year old male, POD 7 exploratory laparotomy following motor vehicle collision, remains intubated for VAP. Formal Patient Presentation [Systems Based] Neurologic (Neuro) Diagnosis: Exam/ objective data. GCS, reflexes, pupils. ICP monitor. Medication: continuous infusions, requirements of prn analgesics Plan: Neuro- patient remains intubated and sedated, GCS 11T off sedation, currently on Fentanyl @ 100 mcg/ hr and propofol @ 20. Minimal requirements of prn analgesics. We will wean fentanyl infusion and use enteral multi-modal analgesia. Cardiac Diagnosis: Exam/ objective data. Vitals: describe the trend, know when outliers occurred (for example, an isolated heart rate (HR) of 130 during a procedure at noon the previous day is different from a sustained HR of 130s). If patient has any invasive monitoring, such as arterial pressure waveform analysis (FloTrac, Vigileo), pulmonary artery catheter or central line, include these as well. Medication: Plan: Cardiac: HR 90s-100s, Flotrac shows normal SVV. On norepinephrine, requirement is currently down to only 2 from a max of 10 yesterday, MAP goal of >65. Continue to wean norepinephrine. Remove arterial line once off norepinephrine for 12 hours. Pulmonary (Pulm) Diagnosis: Exam/ objective data: intubated, secretions, breath sounds, breathing pattern. Ventilator settings. Labs: ABG if performed. Imaging: note findings, and describe how it’s changed relative to prior imaging Medication: Plan: Example: Pulm- pt remains intubated, current ventilator settings. CXR still shows bilateral fluffy infiltrates. *on antibiotics day x of x for VAP, CXR worsening/ stable, secretions improving. Then, later: ID- patient is on antibiotics day x of x for UTI, and day x of x for VAP. Gastrointestinal (GI)/ Nutrition Diagnosis: Exam/ objective data: abdominal wounds, drains, stool management system, bowel function, nutrition. Medication: bowel regimen Plan: GI- patient started on tube feeds two days ago, but he’s having minimal stool output. Abdomen is distended and tympanitic. We held feeds this morning and have an abdominal plain film pending. Renal/ Fluids/ Electrolytes (Renal) Diagnosis: Exam/ objective data. IV fluids. Intake/ output. BMP. Medication: Plan: Renal- foley in place with good urine output, I/O 3.2L/2.9L. No continuous IV fluids. Electrolytes within normal limits. Hematologic (Heme) Diagnosis: Exam/ objective data. Labs: Hgb, Plt. Transfusion. Medication: Plan: Heme- stable mild anemia, checking CBC every Monday/ Wednesday/ Friday. Infectious Disease (ID) Diagnosis: Exam/ objective data. Labs: WBC, neutrophils. Culture results (sample source, date, results). Medication: current antimicrobials. Plan: ID- patient is on antibiotics day 2/5 for UTI, and day 2/5 for VAP. He has remained afebrile for the last 48 hrs. His WBC is downtrending. No pending cultures. Endocrine (Endo) Diagnosis: Exam/ objective data. Labs: glucose trend, insulin requirements Medication: Plan: Endo- stress hyperglycemia, glucose range from 210-240. Currently on SSI with 24 hr requirement of 22U. Increase to more aggressive sliding scale, but holding off adding scheduled/ basal insulin while adjusting his enteral nutrition. Prophylaxis/ Lines and Tubes GI prophylaxis DVT prophylaxis Location/ date of invasive lines and tubes Patient is on IV PPI for ulcer prophylaxis, on enoxaparin BID. PICC RUE, day 10. Foley, day 5. Helpful hints: - Be succinct and synthesize the data. Have all the information available if asked, but don’t report every single bit of data. - Some problems can be relevant to multiple systems. For example, ventilator-associated pneumonia is related to the pulmonary system but overlaps with infectious disease. You can pick one system to discuss it, but you can also briefly mention it in the other relevant system. For example: Pulmonary- patient remains intubated, on antibiotics day x of x for VAP, CXR worsening/ stable, secretions improving. Then, later: ID- patient is on antibiotics day x of x for UTI, and day x of x for VAP. - If the patient’s BMP is normal, you can state that instead of reading every value. If there is one lab value that is abnormal but the remainder is normal, you can say “normal except for [elevated potassium of 5.5]” - Be thoughtful about ordering labs and imaging. Daily CXR purely because a patient is intubated for a bad TBI is not necessarily helpful. Even if the patient is being treated for pneumonia, daily CXR is unlikely to change your management unless there is a clinical change. CXR is appropriate if there are specific interventions that were performed or if the patient has a clinical deterioration- for example, following placement of chest tube for pleural effusion, following 24 hours of aggressive diuresis, for evaluation of acute dyspnea/ hypoxia. - Don’t repeat information presented by other team members- if the nurse has already provided infusion rates or RT has already provided ventilator settings, just move through the next part of the presentation. ICU Rounds .pdf Download PDF • 46KB A-F Bundle .pdf Download PDF • 33KB Previous Next

Maybe you Should Talk to Someone A Therapist, HER Therapist, and Our Lives Revealed Some of my favorite quotes Peace. It does not mean to be in a place where there is no noise, trouble or hard work. It means to be in the midst of these things and still be calm in your heart. (p. 289). HMH Books. Kindle Edition. “Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom. (p. 289). HMH Books. Kindle Edition. Which is why, in the end, after several drafts and revisions, Julie decided to keep her obituary simple: “For every single day of her thirty-five years,” she wanted it to read, “Julie Callahan Blue was loved.” Love wins. (p. 313). HMH Books. Kindle Edition. Previous Next

< Back Shakshuka- A North African Dish Ingredients 1 large red bell pepper, thinly sliced 1 large yellow bell pepper, sliced 1 red onion, sliced 3-4 garlic cloves, diced ¾ tsp salt cracked pepper to taste 1 tsp cumin 1 tsp sugar ½ tsp smoked paprika ½ tsp chili flakes 3 medium tomatoes diced small ⅓ c white wine or water 1 T fresh basil ribbons or chopped Italian parsley 4 -6 Extra large organic eggs Other optional additions: crumbled feta or goat cheese 1 C browned chorizo ¼ C finely diced spanish style cured Chorizo or Merguez, a North African spiced sausage Instructions 1. Preheat oven to 400F. 2. In a large cast iron skillet, heat the olive oil over medium heat. Add the onion and cook until tender, about 5 minutes. If adding raw chorizo, brown it with the onions. 3. Add the sliced peppers and garlic, and turn heat down to med-low and cook for 5 more minutes, until peppers are tender. If adding the cured spanish chorizo or Merguez sausage, add it now. Add all spices, sugar and salt. Cook for 2 more minutes. Add fresh tomatoes and white wine. 4. Simmer on low for 15 minutes, adding more water if it gets too dry or thick- you want a stew-like consistency. After tomatoes cook down, taste, it should be full flavored- adjust salt and sugar if necessary. Crack 4-6 eggs over the mixture, sprinkling each egg with salt and cracked pepper. Add crumble goat cheese or feta over the top and place in the 400F oven. 5. Bake until egg whites are cooked (about 7 minutes) and yolks are still soft. Remove from oven and top with fresh basil (or Italian parsley). Serve with toast or crusty bread. Veggies sizzling Previous Ready for the oven Yummy! Next

< Back Pre-Peritoneal Packing When: blunt pelvic trauma with hemodynamic instability. How: 1. Low vertical midline incision, stop a short distance below the umbilicus. 2. Split rectus, retract laterally, the peritoneum is just behind the rectus. 3. Slide hand directly under the rectus- palm toward peritoneum and back of your hand toward rectus. Bluntly dissect laterally toward ASIS. 4. Retract rectus anteriorly, use your other hand to place rolled laps in the potential space you just developed [This how-to guide was designed in response to a query from @obcast ] References Smith WR et al. Retroperitoneal packing as a resuscitation technique for hemodynamically unstable patients with pelvic fractures: report of two representative cases and a description of technique. J Trauma. 2005 Dec;59(6):1510-4 Filiberto DM and Fox AD. Preperitoneal pelvic packing: Technique and outcomes. Int J Surg. 2016 Sep;33(Pt B):222-224. Previous Next

Scienceblind Why Our Intuitive Theories About the World Are So Often Wrong Intuitive theories- our best guess as to why we observe the events we do and how we can intervene in those events to change them. Infer causality from our observations. Similar to historical theories- how we used to understand things before we had the ability to understand the reality (like heat as an “object” versus “energy”). Emergent process- system wide (no clear cause/ effect explanation), equilibrium-seeking, simultaneous, ongoing. Heat, weather, evolution are all emergent processes. Molecular theory, scientific theory. Holistic theory- matter is continuous and has heft and bulk Intuitive theories of the physical world Matter- substances are holistic and discrete, instead of particulate and divisible. Conservation- clay flattened, water poured from short fat glass to tall skinny glass. The difference between weight and heft, volume and bulk? Energy- heat, light and sound viewed as substance instead of emergent property. Why can you touch the 400 degree air in the oven but not the pan itself (without oven mitts)? The pan transfers heat better than air. How do we change from viewing “sound” as an “object” to viewing it as “energy”? First, we stop attributing permanence (noise doesn’t continue forever), then weight (clock doesn’t become lighter with each chime) and then mass (noise can pass through a wall, doesn’t have to maneuver around wall). Extra-missionist- rays go out of the eye and then return to create vision vs intro-missionist- rays enter the eye to create vision. Gravity- weight is an intrinsic property of objects instead of relation between mass and gravity. Objects don’t fall because they’re heavy- they fall when they don’t have upward force on them that exceeds gravity (center of gravity). Motion- force is something transferred between objections (“impetus”), instead of external factor changing the objects motion. What path will an object take- for example, a ball in a spiral slide- takes straight path after exiting, doesn’t gain an inherent “spiral” motion. Cosmos- earth is a motionless plane orbited by the sun. Changing of the tides, seasons (tilt of the earth as it revolves around the sun, the side closest to the sun is summer). Earth- continents and mountains are eternal and unchanging vs transient/ dynamic. Tectonic plates- similar land features on different coasts. Greenhouse effect and global warming- humans causing it, but the earth will live beyond us. Vitalism- living things possess an internal energy, or life force, that allows those things to move and to grow. Essentialism is the idea that an organism’s outward appearance and behavior are products of its inner nature, or “essence.” Intuitive theories of the biological world Life- animals viewed as psychological agents vs organic machines. Death= cessation of biological processes. Growth- eating is for satiation rather than nourishment, aging is a series of discrete changes vs continuous change. Vitalism- living things possess an internal energy, or life force, that allows those things to move and to grow. Essentialism is the idea that an organism’s outward appearance and behavior are products of its inner nature, or “essence.” Inheritance- parent-offspring resemblance viewed as nurture, vs transfer of genetic information. Illness- disease is due to supernatural causes, instead of microorganisms. Adaptation- evolution is the transformation of an entire population (butterflies become slightly darker with each generation) vs selective survival (darker butterflies survive to reproduce). Ancestry- species develop linearly (monkey→ ape→ human) rather than branching from common ancestor. Previous Next

< Back Mentorship What is mentorship? Mentorship is a partnership between a more experienced and knowledgeable individual (mentor) and a less experienced individual (mentee) seeking to learn, develop skills, and advance their career in the healthcare profession. The mentor is typically someone who has achieved a level of success that the mentee aspires to reach. Through this relationship, the mentee, who could be a medical student, trainee (resident or fellow), or junior staff member, can benefit from the mentor's expertise and past experiences, gaining valuable insights into the healthcare profession. The mentor can serve as an advisor, consultant, or coach depending on the mentor's expertise and the mentee's needs. For example, a mentorship relationship can be designed to help the mentee improve clinical skills, navigate the job search process, or advance research endeavors. It's common to have different mentors for different purposes, as each mentor may have different strengths. Mentorship also provides networking opportunities, as the mentor can facilitate connections between the mentee and other professionals in the field. In summary, mentorship is a valuable tool for professional development in healthcare, offering guidance, support, and connections that can help mentees achieve their goals. Do I really need a mentor? Throughout medical school and residency, I didn't have any formal mentors, but I did actively seek the opinions, advice, and feedback of several surgeons I respected. As a young staff surgeon, I still didn't actively pursue mentorship, though I now recognize that it could have been highly beneficial. My first formal mentorship relationship was late in my training, when I was an Acute Care Surgery fellow and I was required to choose a staff member as a mentor. It's not uncommon for trainees to lack mentors, and one possible explanation resonates with me. "Many young people today who end up in residency…have been on a fast track. They’re essentially high-achieving, highly driven professional students who have been on a fairly regimented pathway…and they haven’t reached a point where there are multiple pathways they could take."(1) As someone who has been on a straight path since high school, progressing from high school to medical school to residency to being a junior faculty, I potentially missed out on a valuable asset. It's important to note that having a mentor is not a requirement, but developing a strong relationship with a mentor can positively influence one's success. It's highly recommended that individuals consider formal mentorship, but it's equally important to recognize that they have the ability to end relationships that are toxic or not a good fit. How do I find a mentor? Mentorship relationships can be an essential aspect of professional growth for medical trainees. These relationships can develop organically or be assigned by program directors in residency or fellowship programs. If you are assigned a mentor, it can be a great experience, but it is also possible that you may not mesh well if the assignment was not carefully considered. It's essential to recognize that if you find yourself in a mentor-mentee relationship that is not productive, amicable, or beneficial, it's okay to end the relationship and seek out another mentor. On the other hand, organic mentorship relationships can also be incredibly fruitful. As you work with various individuals in different settings, such as the operating room, during rounds, or while discussing consults, you will begin to form opinions and may find that you gravitate towards a particular person. If you respect and trust them and they demonstrate skills or expertise that you want to learn from, they might be a viable option as a mentor. The process of finding a mentor can be as simple as asking the person you would like to work with if they would be willing to mentor you. Remember, the worst they can do is say no, so it's worth taking the risk to ask. If they don't have the time to commit to being a mentor, they may be able to connect you with someone else who could be a good fit. It's important to recognize that mentorship relationships require effort from both the mentor and the mentee. While your mentor can offer guidance, support, and feedback, it's ultimately up to you to take ownership of your own professional development. Be clear about your goals, seek out feedback, and be receptive to constructive criticism. By putting in the work, you can make the most of your mentorship relationship and set yourself up for success in your career. Finding a mentor can be a great way to help you achieve your personal and professional goals, but it's important to have a plan in place to make the most of the relationship. Here are some steps you can take after finding a mentor to ensure that you get the most out of the relationship: 1. Set specific goals: Take some time to think about what you hope to gain from your mentorship. Are you looking to improve your skills in a particular area? Do you want help navigating a career transition? By setting specific goals, you can make sure that you and your mentor are on the same page and working towards the same objectives. 2. Establish communication: Once you've set your goals, it's important to establish how you will communicate with your mentor and how frequently you will meet. This can be done through formal meetings, phone calls, or casual chats over coffee. Make sure that both you and your mentor are comfortable with the frequency and type of communication. 3. Complete assignments or tasks: Your mentor may assign you tasks or provide you with guidance on specific projects. It's important to take these assignments seriously and complete them as directed. This could be anything from revising your CV to drafting a study protocol. By following through on these tasks, you can demonstrate your commitment to the mentorship and make progress towards your goals. 4. Reassess and refine: As you work with your mentor, it's important to regularly reassess your progress and refine your goals. This may involve checking off completed tasks, adding new objectives, or removing items that are no longer a priority. By keeping your goals current and relevant, you can make sure that you are making the most of the mentorship. Overall, finding a mentor can be an incredibly valuable experience. By taking the time to set goals, establish communication, complete assignments, and reassess your progress, you can make sure that you get the most out of the relationship and achieve your personal and professional objectives. 1. Darves B. Physician Mentorship: Why It’s Important, and How to Find and Sustain Relationships. NEJM Career Center. 2018 Feb. Previous Next

< Back Anal Fissure What is an anal fissure? Patient information: Anal fissure [American College of Colon and Rectal Surgeons] Patient education: Anal fissure (Beyond the Basics) [UpToDate] Trauma from hard stool (constipation) creates a tear in the anoderm distal to the dentate line. Pain leads to internal sphincter spasm, setting up a vicious cycle! Symptoms- severe pain during and immediately following a bowel movement ("like pooping glass", "passing a razor blade"), blood on toilet paper with wiping. This often leads to fear of having bowel movements. Pain leads to muscle spasm→ higher pressure→ vicious cycle. Diagnosis- classic history is almost enough, but pain with effacement of the buttocks and visualization of a tear in the anoderm confirms. Don’t torture them with a digital rectal exam! On exam, typically seen in the posterior midline. If a fissure is seen in a different location, consider IBD, trauma, infection (Tuberculosis, sexually transmitted diseases), cancer. Source: UpToDate Images: Anal Fissure Anatomy What is conservative management for an anal fissure? See “ Anorectal Disease: How do I prevent anorectal disease? ” Improving bowel habits is the first-line treatment for an anal fissure. See patient handouts below. The majority of patients with an acute fissure heal with conservative management. If a fissure has been present for a long time, it is less likely to heal with conservative therapy. Sitz baths- fill a tube with water as warm as you can tolerate, and soak your bottom after every bowel movement and at least 3 times per day. Topical compounds- nitrates, calcium channel blockers→ relax muscle→ improved blood flow→ allows healing. Local anesthetics can also improve symptoms during the healing process. Avoid suppositories, Tucks pads, and Preparation H. These would be painful and won’t treat the disease. This is why diagnosis is vital. Patient Info- Anal Fissure .pdf Download PDF • 59KB Patient Info- Fiber Guide .pdf Download PDF • 68KB What is the operative management for an anal fissure? For the few patients who fail a trial of conservative therapy, surgical intervention can provide relief. Botulinum toxin (Botox) blocks neuromuscular function leading to muscle relaxation. Yes, this is the same Botox that is used to treat wrinkles. Low risk of complications. Lateral internal sphincterotomy is the treatment of choice for chronic fissures that have failed to resolve with other interventions. More successful healing compared to other interventions. Risk of incontinence (inability to control the passage of gas and stool). If incontinence occurs, the inability to control gas is more common than the inability to control liquid stool, which is more common than the inability to control solid stool. Previous Next