< Back Respiratory Failure- it hurts to breathe A 47-year-old male sustains multiple traumatic injuries after being struck by a vehicle while on the side of the road. He had severe thoracic trauma (bilateral pulmonary contusions), bilateral femur fractures and a liver laceration. He also had a severe TBI, requring intubation shortly after his arrival. 10 days into his hospital stay, he still requires ventilatory support. What are some of the potential causes of the patients ongoing requirement for mechanical ventilatory support? Pain from rib fractures, pneumonia, ARDS, pulmonary embolism, fat embolism, pulmonary contusions, loss of chest wall stability due to severe thoracic trauma, hypomagnesemia, volume overload, retained hemothorax, poor nutrition from inadequate protein delivery. He is undergoing a trial of spontaneous ventilation, but he develops tachypnea and hypoxemia and appears to be struggling on the ventilator. What are some of the initial steps in evaluating this patient? Physical exam (pulmonary exam, assess for edema), bedside ultrasound (pleural effusion, pneumothorax). Chest x-ray- look for infiltrates. ABG, EKG, review volume status. His chest x-ray is shown below. What do you see? Trachea midline, no effusions. Bilateral fluffy infiltrates. His current ventilator settings and ABG results are shown below. Ventilator settings: RR 12, TV 450, PEEP 10, FiO2 50. Arterial blood gas: pH 7.34, PaCO2 42, PaO2 64, HCO3 24 What does this tell you about his oxygenation? PaO2:FiO2 ratio is an indicator of oxygenation. This patients P:F ratio is 182. See below for explanation. What diagnosis is this consistent with? Acute respiratory distress syndrome. What are the management principles when caring for a patient with ARDS? What are your initial ventilator management strategies? ARDS is not a primary diagnosis, so it is important to treat the underlying cause (pancreatitis, pneumonia, etc). Minimize further insults to the lungs. Optimize ventilator strategies- low tidal volume, target PEEP/FiO2 combination to target SpO2 88-95% Diagnosis and Management of ARDS Etiologies of ARDS Pneumonia, pulmonary contusions, aspiration, inhalation Trauma, burn Pancreatitis Transfusion-related acute lung injury (TRALI) ARDS diagnostic criteria: The Berlin Definition [1] Onset of respiratory failure within 1 week of an insult that is known to cause ARDS Bilateral fluffy infiltrates on CXR not explained by effusions/ infiltrates/ contusions/ lung collapse Respiratory failure not related to heart failure or fluid overload Oxygenation PaO2/FiO2 ratio with PEEP ≥5 cm H2O. Mild 200-300, moderate 100-200, severe ≤100. Basic principles of ARDS management [2,3] Low tidal volume ventilation- 4-8 mL/kg predicted body weight. Prevent volutrauma. Permissive hypercapnia- low TV ventilation leads to decreased minute ventilation, which leads to CO2 retention (hypercapnia). Hypercapnia is tolerated as long as pH remains above 7.2. Positive end-expiratory pressure (PEEP)- goal is avoiding overdistension and optimizing recruitment If ↑PEEP→ ↓plateau pressure: recruitmentIf ↑PEEP→ ↑plateau pressure: overdistension Optimizing mean airway pressure (MAP). Prolonged inspiratory:expiratory ratio Target plateau pressure <30, driving pressure ≤15. Recruitment manuevers Advanced strategies for persistent hypoxemia Prone positioning Airway Pressure Release Ventilation (APRV) Neuromuscular blockade Inhaled vasodilators Prostacyclin and nitric oxide ECMO High frequency oscillatory ventilation Open lung ventilation Dexamethasone Extracorporeal carbon dioxide removal (ECCO2R) References Ferguson ND et al. The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material. Intensive Care Med. 2012;38(10):1573-1582. Narendra DK et al. Update in Management of Severe Hypoxemic Respiratory Failure. Chest. 2017 Oct;152(4):867-879. SCCM Clinical Practice Guideline. Fan E et al. ATS/ SCCM CPG: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2017;195(9):1253-1263. Basic Principles of Ventilatory Management of ARDS Previous Next

What language are we speaking? Speaking Greek < Back What language are we speaking? Medicine has a language all its own. Sometimes we use formal words for common terms, like sputum or phlegm to refer to snot. But a lot of words are unique to the medical field. When speaking with patients and families, the most important thing is communicating effectively. Using a slew of foreign and formal words might sound impressive, but everyone will likely be more confused when you leave the room. After years of education and training, words and phrases in the medical dictionary become second nature. Our conversations with colleagues, consultants, and peers are frequently saturated with this unique lexicon. Sometimes this even spills into your conversations outside of work, and your family and friends might start to pick up some of your common work terms. Patients and their families are not fluent in the language of healthcare unless they are employed in healthcare or have experienced frequent interactions with the healthcare field, such as being a caregiver for an ill family member or suffering from a chronic illness. Once you learn something, it’s difficult to remember a time when you didn’t know. If you’ve worked in healthcare, it’s obvious that laparoscopic cholecystectomy means using tiny incisions and long instruments to remove the gallbladder through the belly button. But unless you’ve had one yourself or know someone who has had one, these words might have little meaning. This language barrier can be even more challenging in the stressful environment encountered in the ICU. Several factors create additional barriers to effective communication. 1. Patients in the ICU are sicker and the threat of death or serious disability is more apparent. This can create emotional distress that occupies or distracts families as they try to ask questions and get answers, impairing their ability to thoroughly understand, even if the healthcare team provides very detailed, comprehensive information. 2. When individuals receive bad news, they process/ remember very little after the initial shocking revelation. 3. The higher acuity and sometimes the need for urgent intervention can add time constraints. This creates an additional barrier to effective communication- having to convey the information and potentially obtain consent for treatment and procedures while balancing the ever-present demands of multiple urgent procedures and critical patients to attend to. Families can get information from different members of the healthcare team. Sometimes the nature of the conversation demands the skills of the most experienced provider. However, young trainees sometimes converse with families as well. It’s easy to forget the process of learning how to effectively communicate with families in difficult situations. Listening to phone conversations between team members and family can be enlightening. As young trainees are becoming much more facile with the unique language of the ICU, it can start to infiltrate these discussions. For example, imagine you are caring for a patient who was just admitted to the ICU with a severe traumatic brain injury. When you’re reporting to the accepting team, you’ll use words like subdural hematoma, midline shift, cerebral edema, and severe TBI. When discussing the patient's current clinical status, you might mention that they are over-breathing the ventilator or that they don’t have brainstem reflexes. When developing a management plan, you might discuss the utility of ICP monitoring and debate the use of a bolt or an EVD, the benefits of hypertonic saline versus mannitol for hyperosmolar therapy, whether or not to hyperventilate the patient and the potential for a craniectomy. While these will be readily understood by your colleagues, these are likely foreign terms for most family members. So here are some tips for talking to family and friends, especially during initial conversations. 1. Avoid unfamiliar medical terminology (for example: severe TBI, hypertonic saline). Instead, opt for descriptors such as “bad head injury” or “medication to protect the brain”. 2. Avoid unnecessary details. Don’t ramble on about everything that has happened, especially while they are waiting to hear if their loved one is alive or dead. After you’ve told them their family member is alive, they aren’t likely to hear much else. 3. Avoid revealing that a patient has died over the phone, especially in your initial discussion with the family. 4. Avoid acronyms (for example: TBI, GCS) 5. DO give them a chance to ask questions. 6. DO encourage them to write down their questions as they think of them and reassure them that they can ask questions throughout the process. Previous Next

Ratios < Back Kitchen Hacks #5 Ratios Cooking with Ratios Bread 5:3 flour to water- for example, 300g flour and 180g water. With this ratio in your arsenal, the world of bread is at your fingertips. You can explore different flours, hydrations, and additions like seeds and nuts from here. Salt: Around 2% of the flour weight (e.g. 6g salt for 300g flour) Yeast: Around 1% of the flour weight (e.g. 3g yeast for 300g flour) Muffin/Quick Breads 2:2:1:1 flour:liquid:eggs:fat Baker Move: Baking times and temps can vary based on something as simple as the humidity in the air. Pros test the doneness of muffins, quick breads and cakes by simply inserting a toothpick. If it comes out clean, they are ready to cool. Biscuit 3:2:1 flour:liquid:fat Baker Move: Pros always scoop flour, sugar or other dry ingredient into a measuring cup, then use the back of a knife or other straight edge to level it off. Vinaigrette 3:1 oil to vinegar. Add herbs, garlic, or mustard to elevate your dressing Cookies 3:2:1 flour:butter:sugar Other ingredients like eggs, baking powder, and flavourings can be added, but the core 3:2:1 ratio for the main dry, fat, and sweet components is the foundation. Baker Move: Using a dough scoop (like a small ice cream scoop) to portion equal-size cookies adds a professional touch to your finished cookie plate. Pound Cake 1:1:1:1 flour: egg: fat (unsalted butter): sugar Baker Move: Pull your butter and eggs out of the fridge a couple of hours before you're ready to bake. Room-temperature butter is better for creaming, and you'll want the eggs at the same temperature to prevent them from seizing. Pancakes 2 parts flour: 2 parts liquid: 1 part eggs: 1/2-part fat Baker Move: Slowly incorporate the liquid into the dry ingredients while whisking constantly for effortless, lump-free pancake batter. Meringue 2 parts sugar: 1 part egg whites or 1 part sugar: 1 part egg yolks Baker Move: Avoid cracks in your perfectly piped meringues by keeping your oven door closed while they dry out. Yep, that means no peeking. Pie Dough 3:2:1 flour:butter:water Baker Move: Soggy-bottomed pie crusts, be gone! Pros know to par-bake their crusts for fresh fillings. Fritter 2:2:1 flour:liquid:egg Baker Move: The key to a crispy fritter is to never crowd the pan. Drop too many in the frying oil at once and the temperature will plummet, producing a greasy, mushy fritter. Custard 2:1 eggs:liquid Baker Move: Once you have that ratio down, remember to strain your cooked custard through a fine mesh sieve to remove any lumps. Crepes 1/2:1:1 flour:liquid:egg Baker Move: Crepe batter needs time to set up, preferably overnight in the fridge. Links Cooking with Ratios Food Network Previous Next

3 Everybody Lies Big Data, New Data, and What the Internet Can Tell Us About Who We Really Are - The staggering amount of data available and the power to make predictions. - Internet search bars have entered society as a secret place to ask our most urgent/ personal/ embarrassing questions without risk of guilt or shame from others discovering intimate details about us. People lie on job interviews, online surveys, and almost anywhere they are at risk of being revealed, which introduces a significant bias in database queries. In contrast, there is no motivation to lie to the anonymous search bar. - Evaluating internet searches can reveal an infinite amount of information about society as a whole. Monitoring internet searches during presidential addresses, evaluating searches for unemployment offices, what to say on first dates- there is so much data that can be harnessed to understand society. Previous Next

< Back Before Surgery American College of Surgeons (ACS) Operation Brochures for Patients Patient Education: Preparing for Your Surgery How Can I Be Strong for Surgery? Strong for Surgery is a program that works with surgeons and hospitals to provide tools like checklists that surgeons can use to assess your risks in four target areas: nutrition, blood sugar control, smoking cessation, and medications. You can lower your risk by being better prepared for your operation. NSQIP Surgical Risk Calculator Disclaimer: The ACS NSQIP Surgical Risk Calculator estimates the chance of an unfavorable outcome (such as a complication or death) after surgery. The risk is estimated based upon information the patient gives to the healthcare provider about prior health history. The estimates are calculated using data from a large number of patients who had a surgical procedure similar to the one the patient may have. Previous Next

< Back AKI...pending Management of Acute Kidney Injury Previous Next

< Back Appendicitis What is appendicitis? The appendix is a small worm-like structure that hangs from where the small and large bowel connect in your right lower abdomen. It can become inflamed and cause pain. What does surgery entail? What are the risks of the procedure? The surgery to remove your appendix involves using a camera and thin instruments. We typically make 3 incisions- one at your belly button, one right above your pubic bone and one in the left lower abdomen. We divide the appendix with a stapler and remove it. You’ll have a foley in your bladder to help get your bladder out of the way because one of the ports is placed right over the bladder. The folly goes in after you go to sleep and is removed before you wake up. It might burn the first time you pee after surgery. There is a risk of infection following an appendectomy. Bacteria live in the appendix and when we divide it, the bacteria can fall out and form an abscess. This risk is higher if your appendix is ruptured at the time of surgery. This typically presents very similar to appendicitis, because it’s an infection in the same part of your abdomen. Most of the time that can be managed without surgery. We can have our radiology colleagues place a drain into the abscess cavity. What can I expect post-operatively? You will have several small incisions from the laparoscopic port sites. They will have absorbable sutures, nothing that needs to be removed. You will have glue or gauze and paper tape on the incisions. The glue will peel off on its own in 10-14 days. If you have gauze, you can remove this in two days and shower like normal. You will have paper tape strips on the incision, and these will peel off on their own. You are at risk for a hernia through the small incisions, so avoid heavy lifting for 4 weeks after surgery. You may take acetaminophen (Tylenol) and ibuprofen (Motrin) as needed for pain. These can be taken at the same time. Take the narcotic pain medication if your pain is severe despite the acetaminophen and ibuprofen. After the few first days, you should work on decreasing the number of narcotics that you are taking. What can I eat after surgery? There are no specific dietary restrictions. However, if you eat a fatty meal, it may cause loose stool (diarrhea) until your body adjusts to not having your gallbladder, which previously stored the chemicals used to digest fatty food. This is seen in about 10% of patients and usually resolves. If it lasts more than a few weeks, there are medication options to treat this. What should I be worried about after surgery? If you have fever >101 F, severe nausea/ vomiting, inability to tolerate liquids, severe abdominal pain, increasing redness, or drainage from your incisions. Patient Information from Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Appendix Removal (Appendectomy) Surgery American College of Surgeons Appendectomy: Surgical Removal of the Appendix Previous Next

< Back Chronic Upper Abdominal Pain A 65-year-old female with chronic non-specific abdominal pain develops acute severe pain in her epigastrium. She presents to the ED for evaluation. What's on the differential diagnosis? Perforated hollow viscus Gastritis Peptic ulcer disease Pancreatitis Biliary pathology- cholecystitis, choledocholithiasis, hepatitis Pneumonia Myocardial ischemia What are the relevant clinical questions and what is included in a focused physical exam? Further details about the abdominal pain- prior similar episodes, onset/ duration, aggravating/ alleviating factors, constant or intermittent, radiating pain, severity, quality of pain (burning, stabbing, cramps). Associated symptoms- systemic symptoms. Fevers/ chills. Nausea/ vomiting. Change in color of urine or stool? Any prior medical or surgical history? Any medications? Smoker? Exam- abdominal palpation- identify tenderness and presence of peritonitis. The pain is stabbing and constant, and she's never had this pain before. She occasionally has right shoulder pain. She reports nausea and loss of appetite, but denies fevers/ chills/ vomiting. She had tea-colored urine and pale white stool a couple days ago. She has no medical or surgical history and is a non-smoker. On exam, she is afebrile, heart rate in the 90s. She is tender in the right upper quadrant with minimal palpation. What is the initial diagnostic workup? Labs: CBC, amylase/ lipase, hepatic enzymes, bilirubin Right upper quadrant ultrasound Possible computed tomography What ultrasound findings are consistent with cholelithiasis? Masses in the gallbladder that are echogenic (reflect on the anterior surface) with a posterior shadow and mobile/ dependent (move with changes in patient position). What ultrasound findings are consistent with acute calculous cholecystitis? Gallstones + gallbladder wall thickening + pericholecystic fluid +/- positive sonographic Murphys sign. What radiographic and laboratory findings are consistent with choledocholithiasis? Dilated common bile duct, stones visualized in the common bile duct, elevated bilirubin. What clinical/ radiologic/ laboratory findings are consistent with acute calculous cholecystitis? Criteria are based on Tokyo guidelines.[1] Local signs of inflammation- Murphy’s sign, RUQ mass/pain/tenderness Systemic signs of inflammation- fever, elevated CRP, elevated WBC count Imaging findings characteristic of acute cholecystitis Suspected diagnosis- one local sign + one systemic sign Definite diagnosis- one local sign + one systemic sign + imaging findings An ultrasound reveals gallstones, gallbladder wall thickening, and a dilated common bile duct. Her bilirubin is 2. Diagnosis? Cholecystitis with high risk for choledocholithiasis. Right Upper Quadrant Ultrasound- Gallstones Case courtesy of Maulik S Patel, Radiopaedia.org . From the case rID: 20542 Right Upper Quadrant Ultrasound- Gallbladder Wall Thickening Case courtesy of RMH Core Conditions, Radiopaedia.org . From the case rID: 3802 Patient was taken to the OR and underwent uncomplicated laparoscopic cholecystectomy. Intraoperative cholangiogram revealed multiple stones in the distal common bile duct. Despite multiple attempts, stone retrieval was unsuccessful. She underwent a postoperative endoscopic retrograde cholangiopancreatography (ERCP) with successful stone extraction. SAGES Guidelines on Diagnosis and Management of Choledocholithiasis Cholelithiasis, Predicting Likelihood of Choledocholithiasis Choledocholithiasis Management Algorithm Evaluation and Management of Acute Cholecystitis Diagnosis History- right upper quadrant/ epigastric pain, nausea/ vomiting. Labs- CBC, renal panel, LFTs. Radiology- right upper quadrant ultrasound. - Cholelithiasis: echogenic masses in the gallbladder with a posterior shadow that are mobile (move with changes in patient position). - Acute calculous cholecystitis: gallstones + gallbladder wall thickening + pericholecystic fluid +/- positive sonographic Murphys sign. Diagnostic Criteria for Acute Cholecystitis- Tokyo 2018 Guidelines[1] Local signs of inflammation- Murphy’s sign, RUQ mass/pain/tenderness Systemic signs of inflammation- fever, elevated CRP, elevated WBC count Imaging findings characteristic of acute cholecystitis Suspected diagnosis- one local sign + one systemic sign Definite diagnosis - one local sign + one systemic sign + imaging findings Management Cholecystitis is managed with early laparoscopic cholecystectomy unless the patient is too ill to tolerate surgery.[2] A percutaneous cholecystostomy is a minimally-invasive option for high-risk patients, avoiding the risk of general anesthesia. However, in a recent study of high-risk patients, cholecystectomy was associated with fewer complications than percutaneous cholecystostomy.[3] Evaluation and Management of Choledocholithiasis Diagnosis- dilated common bile duct, stones visualized in the common bile duct, elevated bilirubin. Management- common bile duct stones are managed with endoscopic or operative stone extraction.[4,5] References Yokoe M et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25(1):41-54. Okamoto K et al. Tokyo Guidelines 2018: Flowchart for the management of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25(1):55-72. Loozen CS et al. Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): multicentre randomised clinical trial. BMJ. 2018;363:k3965 . Manning A et al. Protocol-Driven Management of Suspected Common Duct Stones. J Am Coll Surg. 2017;224(4):645-649. Clinical Spotlight Review: Management of Choledocholithiasis - A SAGES Publication. SAGES. Accessed July 13, 2022. Previous Next

< Back Wound Care American College of Surgeons: Home Skills for Patients Adult Colostomy/Ileostomy - collection of resources to help you prepare for managing your ostomy, including videos and a home skills kit. Your Colostomy/Ileostomy Ostomy Home Skills Kit: Adult Colostomy/Ileostomy Wound Management Home Skills Program Drain Care Jackson-Pratt (JP) Drainage Tube: After Hospital Care [Northwestern Medicine] Previous Next

8 Freakanomics A Rogue Economist Explores the Hidden Side of Everything - Hard to include all the different topics under one umbrella. Very controversial topics, such as crime, cheating, the impact of a name. - Correlation versus causation. Does legalized abortion lead to decreased crime? Using broad generalizations, people who grow up with mothers who didn't want them are placed in circumstances that increased their likelihood of involvement in crime. Previous Next

13 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 Sausage Tortellini and Brussels Sprouts Ingredients Sausage Tortellini 2 Tbsp olive oil 2 lbs sausage 2 cloves garlic, minced 1 c vegetable broth 2 c tomato sauce ½ c heavy cream 18 oz tortellini Salt & pepper Brussels Sprouts One package of Brussels Sprouts olive oil black pepper sea salt balsamic vinegar Instructions Sausage Tortellini Heat oil in a large skillet and cook sausage links about 5-7 minutes, until sausages are browned throughout. Add garlic and heat for 30 seconds. Remove sausages from skillet and slice into bite-size pieces. Return sausages to pan along with broth, tomato sauce, cream, and tortellini. Season with salt & pepper. Cover and simmer for 12 minutes. Brussels Sprouts Prepare sprouts by trimming the base and then cutting the sprouts in half or quarters, and then place them in a medium-sized bowl. Drizzle a small amount of olive oil and balsalmic vinegar, and then sprinkle black pepper and sea salt. Toss to coat the sprouts, let sit for at least 30 min. Roast at 400 for 20-30 min, toss halfway through. Sausages cooking Previous Tortellini in Sauce Brussels Sprouts Next