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1 A Field Guide to Lies Critical Thinking in the Information Age - Explains common misuses of statistics and misrepresentation of probability. Use common sense as the first line of defense. This impacts advertising, criminal trials (what is the likelihood that the defendant is guilty based on the blood found at the scene vs whats the possibility that any other individual is guilty based on the blood found at the scene). - Post hoc ergo propter hoc- After this, therefore because of this. Because this event followed another event, the subsequent event must have been caused by the first event. We link events that might be temporarily related but aren't actually cause and effect. - Likelihood of two unrelated events both happening= probability of event 1 x probability of event 2→ lower than the probability of each event independently. Likelihood of flipping one head on a coin followed by flipping another head. - Likelihood of two related events- for example, the likelihood of freezing weather tonight and tomorrow night→ higher given the occurrence of freezing weather the first night. - Vaccines lead to autism? People look at the increased percentage of autism diagnoses. Autism was more frequently diagnosed because it became more understood. Autism is commonly diagnosed between 18-24 months and the MMR vaccine is given around 12 months. - Was 9/11 an inside job? Why did the towers collapse vertically? Easy to overwhelm with questions and theories designed to cast doubt on the events. But structural engineers never found anything suspicious about it. - Breast cancer. Pretest probability- occurrence in the population. 1/8 women develop BrCA. Mammograms can over-call diagnoses (false positive). - Positive test + confirmed diagnosis= true positive - Negative test + confirmed absence of diagnosis= true negative - Positive test + confirmed absence of diagnosis= false positive (low FP= high specificity) - Negative test + confirmed diagnosis= false negative (low FN= high sensitivity) Previous Next

< Back Career Management 1. Create and maintain a curriculum vitae (Microsoft Word template below) that will serve as a comprehensive record of your professional and personal accomplishments. Keep this document up to date by adding new entries as they occur. Include details of your awards, training, leadership positions, committee participation, speaking engagements, and volunteer experiences. Also, list your non-professional talents, such as athletics, foreign language proficiency, and musical abilities. This will help you keep track of your achievements and provide a ready source of information when you need to update your CV. It is recommended to have a master document that includes everything, and you can tailor it to each submission. 2. Develop a personal database to store important documents, such as school transcripts, exam results, awards, training certificates, etc. Organize them in a manner that is easy to access when needed. For hard copies, use a 3-ring binder with clear sheet protectors. For digital copies, create designated folders on your computer. Name each file to in a way that your database is easy to organize and easy to search. This will help you avoid scrambling to locate essential documents when someone requests them. Do not rely on external databases to maintain your documents. Instead, download copies of important records. Create digital copies of important email conversations (scheduling rotations, arranging research projects, agreements, etc). 3. Keep templates of commonly created forms, such as requests for letters of recommendation or sponsorship , personal statements, etc. This will save you time and effort by allowing you to work from a prior document instead of starting from scratch each time. Request LOR Template .docx Download DOCX • 42KB Request Sponsorship Template .docx Download DOCX • 42KB 4. Establish and maintain relationships with trusted advisors who can review your written work, ranging from formal email messages to research papers. Choose someone with expertise in your field as well as someone who has strong spelling and grammar skills. Seek someone who will provide constructive feedback instead of blind positive support. By following these tips, you can build a strong foundation for your medical career and increase your chances of success. Remember, although mentors, friends, and family members can offer sound advice, ultimately, you are the best person to manage your medical training and career. Previous Next

About Doc on the Run 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

A response to the Tweet about being offended by being referred to as anesthesia Don't Call me Anesthesia < Back A response to the Tweet about being offended by being referred to as anesthesia A response to the Twitter post about being offended by being referred to as anesthesia. "Dear world, Please do not call us “anesthesia”. We are not a medication. Acceptable alternatives would be: Are you the anesthesiologist? Are you part of the anesthesia team? What is your role? I’m Dr. X and you are? Thank you for your attention to this PSA." Yes, I often refer to the "head of the bed" (the anesthesia team) as "anesthesia" (or "head of the bed"). There is absolutely no disrespect associated with this. We aren’t actually under the impression that our colleagues in other specialties don’t have names. I don't walk down the hall and wave while saying "hey cardiology how are you" or "hey GI any good scopes recently". But when it’s a chaotic/ urgent situation (responding to a code, crash laparotomy, busy trauma bay), don't get offended that your name isn't at the tip of my tongue. When you walk in and I say "anesthesia is here" or ask "are you anesthesia", everyone in the room automatically understands the change in the dynamic. We all know that someone skilled in airway management and sedation has arrived. Trust me, it's not about reducing you to a bottle of propofol. We don't need your name…we need your skillset. When there is a time for conversation, I will ask your name if I don't know you. Or I'll say, sorry, I know we've met, remind me of your name. As for being in the OR. There is only one team that doesn't take breaks or have teammates that "sub in" in the OR, and that’s the surgical team. Nurses, scrub techs and anesthesia providers all have personnel that can relieve them during the game. So when I look back toward my scrub tech and see a different face, I will ask their name. But when you're on the other side of the blood-brain barrier (also known as the sterile blue drapes), I can't see your face. And again, you might change multiple times throughout the case, so don't expect me to keep tabs on who is there when I'm focused on the task at hand. That’s an unnecessary cognitive load. I have modified my practice this week. In the last step of every preoperative timeout, just before incision, everyone introduces themselves and states their role. It humanizes everyone and serves to remind us that we are on the same team. And breaks up the formality and rote practice that we fall into. Outside the OR, I still don't have the ego to be offended by being referred to as my specialty. You can call me “trauma” or “surgery” whenever you want. I’d be giddy if every time I walked into a room, people stopped and declared “trauma is here”. And every person in that room either knows me (regardless of whether they know or forgot or never knew my name) or doesn't know me. But my name is irrelevant- the patient is the priority. Previous Next

< Back Abdominal Pain- Renal Disease A 72-year-old male with multiple medical co-morbidities presents with several weeks of right-sided abdominal pain. His family reports he hasn't been eating or drinking much. He has a slightly altered mental status and was unable to provide any more detailed history of his symptoms, such as aggravating/ alleviating factors or the relationship of his pain to meals. His medical history is significant for poorly controlled diabetes with neuropathy and renal insufficiency. He has not seen a primary care provider in over 6 months. On exam, he is uncomfortable but not in acute distress. His heart rate is in the 100s, and his blood pressure is normal. He is febrile to 101. He has dry mucous membranes. He has tenderness in the right upper quadrant with a positive Murphys sign. His exam was otherwise unremarkable. Workup? Imaging- right upper quadrant ultrasound Laboratory evaluation- CBC, basic metabolic panel, AST/ALT, bilirubin His labs are remarkable for mild leukocytosis and an elevated Cr (baseline 1.2, currently 2). Imaging was remarkable for cholelithiasis and gallbladder thickening. The EGS team is consulted and the patient is admitted to the surgical ICU given his acute on chronic renal insufficiency. What are the possible etiologies of his renal insufficiency and the initial treatment strategies based on the underlying cause? Pre-renal causes, such as hypovolemia, lead to decreased renal perfusion. Treatment involves volume repletion. Intra-renal causes, such as medication and acute tubular necrosis from sepsis, requires treatment of the underlying cause concurrent with volume repletion, treatment of electrolyte derangements and avoiding further nephrotoxin exposure. Post-renal causes, such as kidney stones or foley catheter malfunction, require relief of the obstruction. Based on the patient's history of decreased oral intake, he is at risk for acute hypovolemia, which can worsen his baseline chronic renal insufficiency. He was treated with volume resuscitation and close monitoring of his urine output. When should he undergo cholecystectomy? If cholecystitis was the precipitating cause, he would likely continue to worsen if his surgery was postponed. If hypovolemia was the precipitating cause, it would benefit from volume resuscitation, which can be administered throughout the operative course. If his renal insufficiency was not an acute change, and it was a slow decline since his last clinic visit, it was unlikely to significantly improve in a short time. The ICU team, EGS team and anesthesiology discussed the risks versus benefits of proceeding with surgery. Regardless of the etiology, postponing his surgery would be unlikely to improve his operative risk profile. We proceeded with laparoscopic cholecystectomy, and he returned to the ICU postoperatively for ongoing resuscitation and monitoring. Management of Renal Failure The causes of renal failure can be categorized into pre-renal, intra-renal, or post-renal. Acute infection can precipitate renal insufficiency, which is associated with poorer outcomes. Pre-Renal Caused by hypovolemia (dehydration) from decreased intake, nausea/ vomiting, excessive diuresis, third-spacing from acute inflammatory processes (pancreatitis), blood loss, inadequate replacement of insensible losses. The common final etiology in pre-renal causes is decreased renal perfusion. Treatment- volume replacement. Intra-Renal Multiple different intra-renal causes, including vascular or micro-vascular etiologies, glomerular disease, and interstitial disease (acute tubular necrosis, medications, and various precipitates such as myoglobin and crystals). The most common acute causes are medication and ATN from ischemic/ sepsis. Treatment involves management of the underlying etiology and supportive care. Post-Renal Caused by any obstruction from the renal pelvis to the urethra, including kidney stones, malignancy (can obstruct anywhere from the ureter to the bladder), retroperitoneal fibrosis, prostate enlargement, blood clots in the bladder or foley catheter malfunction. Treatment involves relief of the obstruction. Acute Cholecystitis with Renal Dysfunction Diabetes and severe cholecystitis (Grade III- organ dysfunction) are risk factors for increased mortality in patients with acute cholecystitis.[1] As noted in the discussion above, it is crucial to weigh the risks and benefits of operative intervention. If there is a modifiable risk factor, such as an acute cardiac event that is amenable to intervention. Escartin A et al. Acute Cholecystitis in Very Elderly Patients: Disease Management, Outcomes, and Risk Factors for Complications. Surgery Research and Practice. 2019;2019:9709242. 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 AKI...pending Management of Acute Kidney Injury Previous Next

7 < Back Training Courses Trauma Courses Advanced Trauma Life Support (ATLS). Systematic team-based management of trauma. Advanced Surgical Skills for Exposure in Trauma (ASSET). Cadaver dissection for vascular exposure. Advanced Trauma Operative Management (ATOM). Live tissue dissection for trauma exposures (pelvic hemorrhage, solid organ and hollow viscus injury management, retroperitoneal exposure, basic management of thoracic trauma). Basic Endovascular Skills for Trauma (BEST). Hands-on training in REBOA. Stop the Bleed. Training course for the public to learn how to control hemorrhage. Critical Care Courses Fundamental Critical Care Support (FCCS). Primer for non-intensivists on critically ill patients' initial management when critical care consultation is not immediately available. Emergency General Surgery Courses Emergency Surgery Course. Training course for non-trauma surgeons. Topics include abdominal sepsis, bowel obstruction, colorectal emergencies, cholecystitis, obstetric emergencies. Training Course Texts Advanced Trauma Life Support (ATLS) 10th Edition Student Course Manual. The newest edition of the manual. Fundamental principles of initial trauma evaluation, diagnosis, and management. Advanced Surgical Skills for Exposure in Trauma: Exposure Techniques When Time Matters (ASSET). Trauma exposures, particularly peripheral vascular access. Advanced Trauma Operative Management (ATOM). Operative techniques in trauma. Trauma: Code Red (Khan). 1st edition, 2019. Companion to the RCSEng Definitive Surgical Trauma Skills Course. Previous Next

< Back Ultrasound: Thoracic Exam Purpose: evaluate for etiology of respiratory failure- pleural fluid collections, pneumothorax, infiltrate, pulmonary edema. Probe Linear for visualization of superficial structures- for example, the pleural interface to evaluate for lung sliding Curvilinear or phased array for the remainder of the lung Findings A and B Lines A-lines- *normal finding*. Hyperechoic arcs parallel to the pleural line. These are seen at intervals that are the same as the interval from the skin to the pleural line. Absence of A lines= change in attenuation coefficient of the lung (edema, consolidation). B-lines- vertical hyperechoic lines, caused by fluid-filled intra-lobular or interlobular septa touching the visceral pleural surface. Examples: cardiogenic pulm edema, ALI, ARDS, pneumonia, ILD or pulm fibrosis, pulm contusion. Comet tail artifact- *normal finding*. Arise from the pleural line and only extend 2-4 cm deep before fading (unlike B lines). They mean that the pleura are in contact. Pleural sliding Shimmering of the hyperechoic pleura→ pleura are in contact. No sliding→ concerning for PTX. There are clinical conditions other than PTX that result in a lack of lung sliding: Effusion, inflammatory adhesions, (pneumonia, ALI), pleurodesis, interstitial or fibrotic lung disease, pleural disease, apnea, severe hyperinflation (asthma, COPD), artifact (subQ air). M mode- sliding→ seashore. No sliding→ barcode. Lung pulse - cardiac motion causes the two pleura to slide Lung point - the junction between the edge of the pneumothorax and the normal lung, where the pleural surfaces meet. One side is sliding and the other side isn’t. Consolidation Air bronchograms- air in small aerated patches of the consolidated lung, or the small bronchi. Dynamic- bubbles move in and out with each breath- no complete bronchial obstruction, more likely true consolidation vs atelectasis. Pneumonia- advanced consolidation (air is completely replaced with fluid)→ lung appear to have a liver-like echogenicity (hepatization) Diaphragm - evaluate diaphragm contraction and thickness. Effusions Spine sign- the presence of a large effusion allowing visualization of the spine. Normally the air in the lung prevents visualization of the spine above the level of the diaphragm, but sound waves can pass through the fluid. Plankton sign- floating debris in an effusion that swirl with pulm or cardiac motion→ blood/ fibrin suggestive of HTX/ exudate Jellyfish sign- consolidated or compressed lung is floating in the pleural fluid. Common Pathologies with their associated ultrasound findings PTX- no lung sliding, M-mode barcode sign, lung point sign, A-lines from intact parietal pleura Pulmonary edema- B lines, normal lung sliding, +/- effusions ARDS- B lines, normal lung sliding References Lung Ultrasound Made Easy: Step-By-Step Guide Lee FC. Lung ultrasound-a primary survey of the acutely dyspneic patient. J Intensive Care. 2016 Aug 31;4(1):57. Previous Next

< Back Chunky Tomato Bisque Ingredients 6 celery ribs, chopped 1 large onion, chopped 1 medium sweet red pepper, chopped 1/4 cup butter, cubed 3 cans (14.5 oz each) diced tomatoes, undrained 1 tablespoon tomato paste 3/4 cup loosely packed basil leaves, coarsely chopped 3 teaspoons sugar 2 teaspoons salt 1/2 teaspoon pepper 1-1/2 cups heavy whipping cream Instructions 1. In a large saucepan, sauté the celery, onion and red pepper in butter for 5-6 minutes or until tender. Add tomatoes and tomato paste. Bring to a boil. Reduce heat; cover and simmer for 40 minutes. 2. Remove from the heat. Stir in the basil, sugar, salt and pepper; cool slightly. 3. Transfer half of the soup mixture to a blender. While processing, gradually add cream; process until pureed. Return to the pan; heat through (do not boil). The vegetables sautéing Previous After blending Dinner is served! Next

< Back Electrolytes...pending Electrolyte Management Previous Next

< Back Stabbed in the Right Thigh A 42-year-old male is brought to the Emergency Department as a Level 1 trauma activation for a stab wound to the right thigh. He was hypotensive before arrival, with SBP in the 70s-80s. Estimated blood loss of 500 mL on the scene. On arrival, the patient is awake and argumentative. His blood pressure is 90 systolic. On a rapid secondary survey, there is no evidence of any other wounds. There is a tourniquet in place to right upper thigh. When the tourniquet is released, there is arterial bleeding from the wound and there is no palpable distal pulse. What do you need to do before leaving the trauma bay? Replace tourniquet. Call OR to have vascular instrument set available, as well as massive transfusion, cell saver, etc. Type and cross for blood transfusion. After ensuring a type and cross, we proceeded to the operating room. How do you want to prep and drape the patient? Any instructions for anesthesia? Wide prep and drape to ensure adequate access for proximal and distal control- this includes prepping the lower abdomen for possible iliac exposure. Also, need to prep contralateral lower extremity for potential saphenous vein harvest. Ultrasound localization of the saphenous prior to prepping can allow identification of the larger vein. Anesthesia will need to monitor hemodynamics and volume status and be prepared for volume resuscitation with blood. In addition, they will have to be vigilant for the repercussion syndrome, the metabolic disturbance following the re-establishment of arterial flow (washout of toxins following ischemia). We placed a pneumatic tourniquet on the patient's upper thigh. We prepped and draped from the umbilicus to the knees, and also prepped and draped the contralateral thigh to have access in case a saphenous vein harvest was required for repair. We made an incision directly over the wound and dissected down to the artery. There was a single wound in the anterior surface of the distal superficial femoral artery. Proximal and distal control was obtained after circumferentially dissecting and placing vessel loops. The artery was divided and spatulated. It was repaired with an end to end tension-free anastomosis. Following arterial repair, we performed a lower extremity fasciotomy. Management of Penetrating Arterial Trauma WTA Algorithm Diagnostic Workup Hard signs- pulsatile bleeding, thrill, bruit, expanding hematoma, pulse deficit, cold pale limb. These patients require operative intervention. A few exceptions can benefit from preoperative imaging to document the presence and location of associated arterial injuries: wounds in the thoracic inlet, shotgun wounds in the extremities, and segmental fractures or fractures at different levels of an extremity. Soft signs- history of pulsatile bleeding, wound near an artery, non-expanding hematoma, neuro deficit, weak pulse, proximity injury. These patients need further workup to evaluate for the presence of arterial injury. An ankle-brachial index should be performed, and if ≤0.9, CT angiography is indicated. If ABI >0.9- no further w/u needed. ABI <0.9- CTA. Principles of arterial repair 1. Plan incision to facilitate proximal and distal control. 2. Ensure adequate back bleeding. Fogarty to remove distal thrombus. 3. Tension-free anastomosis. Adequate lumen. Clean margins. Don't create more damage to the vessel. 3. Consider risk/ benefit of heparinization. Systemic dose: 70-100 units/kg IV. Regional dose: 50U/ml x50 mL. 4. Completion angiogram to document repair. There are various techniques for creating an anastomosis, but the basic principles must be maintained. Recently, I was taught a useful technique [Dr. Feliciano, AAST 2020 Virtual Conference] that prevents tension at one point along the anastomosis. A parachute technique, starting with loosely approximated sutures on the back wall, followed by parachuting the two ends close to continue the suture on the anterior surface of the artery. Indications for fasciotomy include prolonged limb ischemia (>6 hours), combined arterial and venous injuries. 1. Feliciano DV. Evaluation and Management of Peripheral Vascular Injury. Part 1. Western Trauma Association/Critical Decisions in Trauma. J Trauma. 2011;70(6):1551-1555. 2. Feliciano DV. Pitfalls in the management of peripheral vascular injuries . Trauma Surg Acute Care Open. 2017;2:1–8. Parachute Technique [Feliciano] WTA Algorithm for Peripheral Vascular Trauma Previous Next