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< Back Diverticulitis...pending A 52-year-old female developed left lower quadrant abdominal pain, which she thought it was gas pain or indigestion. Unfortunately, the pain worsened and became so severe that she presented to the ER for evaluation. Associated symptoms include nausea, vomiting, lower grade fever and constipation. CBC revealed WBC of 13.5, renal panel was unremarkable. A CT of the abdomen/ pelvis with oral and IV contrast was obtained. CT Scan of Diverticulitis There was minimal thickening and inflammatory changes in the sigmoid colon. She was diagnosed with diverticulitis and discharged with a course of oral antibiotics. Over the next several months, she continued to have pain, with increasingly frequent and intense episodes. She was admitted to the surgery service several months later for a particularly severe episode. She was treated with IV antibiotics and then had resolution of her symptoms and was discharged home. What is the next step? Schedule for colonoscopy to rule underlying pathology. Discuss elective sigmoid colectomy for recurrent episodes of diverticulitis. The plan was to schedule a colonoscopy, but unfortunately, she never had a symptom-free interval. She returned several days later with recurrent pain. She was presented with the option of surgical intervention to remove the inflamed part of her colon. She underwent an uncomplicated laparoscopic sigmoid colectomy with primary anastomosis. Management of Diverticulitis Previously, antibiotics were recommended for the management of diverticulitis, regardless of severity. Two studies (AVOD, DIABOLO) have demonstrated no difference in outcomes for patients with uncomplicated diverticulitis that were managed with or without antibiotics.[1,2] Patients who have an episode of complicated diverticulitis (episode associated with free colon perforation, fistula, abscess, stricture, or obstruction) require an endoscopy to evaluate for underlying malignancy. Indications for Surgery Emergent surgery- acute episode with perforation or peritonitis. Semi-urgent surgery- failure of non-operative management (ie symptoms persist despite bowel rest and antibiotics). Elective colectomy - Resolved episode of diverticulitis associated with abscess/ fistula/ stricture/ obstruction. - Recurrent episodes of uncomplicated diverticulitis that interfere with the patient's lifestyle (frequent episodes, repeated hospital admissions, etc). For More Information on the Management of Diverticulitis ASCRS Patient Information: Diverticular Disease AVOD Trial. Chabok A et al; AVOD Study Group. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg. 2012;99:532–539 . Diabolo Trial. Daniels L et al; Dutch Diverticular Disease (3D) Collaborative Study Group. Randomized clinical trial of observational versus antibiotic treatment for a first episode of CT-proven uncomplicated acute diverticulitis. Br J Surg. 2017;104:52–61. Previous Next

Give me that thing that does the thing… Kelly Snap Mosquito < Back Give me that thing that does the thing… I don’t remember the names of all the instruments in the surgical tray. I swear they have a unique name for each size of the same instrument. Hemostats- crile, snap, stat, mosquito, tonsil, Kelly, Rochester Pean. There is a laundry list of pickups of different shapes with different teeth. And then throw in the culture of different hospitals and specialties. When you place a Bookwalter and you want the short wide curved retractor…do you call it a bladder blade or a curved body wall? And the straight one…is that a Rich or a body wall? In case you’re wondering, the curved retractor is called a Balfour and the straight retractor is called a Kelly. When you’re doing a laparoscopic cholecystectomy, do you ever ask for a wavy grasper or do you call it a prestige? Or something else altogether? As I resident and attending, I used a wavy grasper . Check out the picture. Doesn’t it look like…a wavy? When I was in fellowship, the same instrument was called a prestige. Sounds unnecessarily boastful to me, but whatever. After 9 years using a wavy, it was hard to break the habit and call it a prestige. Thankfully, the scrubs knew what I wanted. I found out it's actually called a Prestige Style Atraumatic Wavy Grasper , so it turns out, we are both right. But that would take way too long to say each time you want to grasp the infundibulum. As we move through training, we develop routines, including our favorite instruments to use during different steps of the operation. When surgeons and scrub techs spend time together during cases, they frequently develop a rhythm, a shorthand. A good scrub tech knows what you want before you even ask. I have had the fortunate of developing several relationships like this. My favorite scrub tech was Kelly. She was a fantastic tech, but also a fantastic person. And the joke of asking for Kelly Kelly never got old. After years of working together, she understood my style and my technique, and always had my next instrument ready. To be honest, it didn’t take years. She knew what I wanted, even if I asked for the wrong thing. She was an invaluable asset to the team, and I miss working in the OR with her. As I mentioned, I don’t remember the names of all the instruments in the surgical tray. A good scrub tech gives you what you want, not what you ask for. While operating, I often extend my hand toward my scrub tech, and as I’m trying to come up with the right name, I start to make gestures with my fingers. Fingers posed like holding a pencil signals scalpel. Thumb and index finger pinched together is my gesture for pickups. Index and middle finger in an open/close motion indicate scissors. Curved fingers, like holding a cup, means I want a retractor. And I request a needle driver by holding the scalpel pose and moving my wrist through a suturing motion. There have been many innovations brought about by the COVID pandemic, and I predict that business will never be conducted the same as before this era. The protective gear worn to prevent viral transmission negatively impacts team communication. This was one of the summary findings of a survey of surgeons, recently published in the World Journal of Surgery.(1) The impact on speech discrimination has been quantified in an experiment with a simulated noisy background.(2) Google “communication impediment COVID protective equipment” and you will encounter many publications regarding the unintended consequences of interventions designed to keep health care personnel safer. Before the pandemic, we already operated wearing masks, which eliminates some of the visual cues of communication. But novel respirators can add several hindrances, including restricting normal jaw movement and muffling the spoken word. The use of the PAPR (powered air-purifying respirator) added a whole new dimension- noise from the fan and battery adds a remarkable hurdle when the surgical team is trying to communicate with other members of the operating team. Admittedly my system is imperfect, and I think a universal sign language for the operating room is a brilliant concept. A proposed system was recently published in the British Journal of Surgery.(3) Signals were developed to request a scalpel, various retractors, forceps, needle drivers, and gauze. This concept is logical, although admittedly, I have become increasingly reticent to accept any innovation just because it appears simple and absent of downsides. Consider the intubation boxes that were developed to prevent aerosol dissemination early in the pandemic. The concept was rational- solid barrier to isolate the patient, great idea! But during simulation, there were multiple hurdles- largely, it makes difficult intubation more challenging, which potentially defeats the purpose by increasing maneuvers and personnel and time to successful intubation. To quote one review: “Well-designed simulations…should always be used to test medical innovations before implementation... “Face validity” alone should not be the basis of innovation adoption.”(4) Is a new language necessary? Do we really need a system to talk to the tech, who is standing closer to us than anyone else in the room, and probably already knows what we want? They are more focused on exactly what is going on in the operative field than anyone else, and they can lean closer or ask us to repeat our request. We need a better way to talk to everyone else in the room! The anesthesiologist who is balancing multiple tasks and the OR nurse who is at least several steps away from the surgeon. What are the potential roadblocks or negative consequences associated with implementation? · Potential for misinterpretation of signals…someone is expecting a pickup and they’re handed a scalpel, which is quickly brought into the field and creates an injury. · The inability of the surgeon to create the signal if both hands are working. · If verbal communication is eliminated, the tech has to constantly watch the surgeons hands, which prevents them from doing other manual tasks, such as loading clip appliers, returning needles to the count box, receiving freshly opened materials from the scrub nurse, etc After all that, I’m not rendering a final verdict. This is an innovative and intriguing concept with a lot of potential. It should be considered and trialed while ensuring that its benefits outweigh the negative impacts before wide-spread implementation. 1. Yánez Benítez C et al. Impact of Personal Protective Equipment on Surgical Performance During the COVID-19 Pandemic. World J Surg. 2020 Sep;44(9):2842-2847 . 2. Hampton T et al. The negative impact of wearing personal protective equipment on communication during coronavirus disease 2019. J Laryngol Otol. 2020 Jul;134(7):577-581 . 3. Leyva-Moraga FA et al. Effective surgical communication during the COVID-19 pandemic: sign language. Br J Surg. 2020;107(10):e429-430 4. Chan A. Should we use an “aerosol box” for intubation? Life in the Fast Lane. 2020 Jul. https://litfl.com/should-we-use-an-aerosol-box-for-intubation/ Previous Next

< Back Vent Mgmt #2: Modes Mandatory Breaths Volume control (volume limited)- set TV and flow, pressure and inspiratory time are the dependent variables. Pressure control (pressure limited)- set inspiratory pressure and inspiratory time, volume and flow are the dependent variables. What is the downside of VC and PC? You can only control one parameter, and the dependent variable varies based on the patient's lung mechanics. For a patient on VC, if their lungs become less compliant, delivering the same tidal volume will generate higher pressure, increasing the risk of barotrauma. For a patient on PC, if their lungs become less compliant, the target pressure will be reached at a lower volume, so there is a risk of decreased ventilation (↑PaCO2). Pressure-regulated volume control (PRVC) is a hybrid mode that attempts to overcome this limitation. The target volume is delivered at the lowest possible inspiratory pressure by assessing the delivered tidal volume at the inspiratory pressure during each breath. What about inverse ratio (IR, IRV-PC) ? Increasing the inspiratory time relative to expiratory time increases mean airway pressure. This can be accomplished with pressure-controlled modes, where inspiratory time can be prolonged (normal ratio 1:2, IRV is when inspiratory time is greater than expiratory time). As discussed, MAP affects the surface available for oxygen exchange. This is why IR can be used to optimize oxygenation. Mandatory and Spontaneous Breaths Synchronized intermittent mandatory ventilation (SIMV)- a variation on VC or PC. The machine delivers mandatory breaths, but the patient can also control spontaneous breaths in between the mandatory breaths. Spontaneous Breaths Pressure support- spontaneous mode, the patient initiates breath, the ventilator provides support to overcome the resistance of breathing through the endotracheal tube, flow is adjusted to maintain the inspiratory pressure. The support is terminated when the flow decreases to <25% of peak flow. The patient controls duration and volume. *This is also a setting that can be adjusted in SIMV for assisting spontaneous breaths between ventilator breaths. Airway Pressure Release Ventilation (APRV)- invasive form of ventilation with BiPAP. The patient breaths spontaneously, alternating between a sustained time (time-high) at a set pressure (pressure-high) with a very brief release (time-low) of pressure (pressure low) to allow expiration. The goal is to maintain a higher MAP to optimize oxygenation. Previous Next

< Back Intracranial Hypertension A 32-year-old male was an unhelmeted motorcyclist who was struck by a car and throw 20 feet. He had decreased alertness on the scene and was urgently transported to the hospital. On arrival to the ED, his GCS was 7 (E2V2M3). He was hemodynamically normal and secondary survey was only remarkable for diffuse road rash and a large scalp laceration. He was intubated for concern for inadequate airway protection. Chest x-ray revealed multiple left sided rib fractures, FAST was positive in the right upper quadrant and the pelvis x-ray was unremarkable. He was taken to the CT scanner for head, c-spine, chest, abdomen and pelvis imaging. He was transported to the trauma ICU as his images were reviewed. Head CT Case courtesy of Derek Smith. From the case rID: 169704. Imaging revealed a large right sided subdural hematoma. He has left lower rib fractures and a grade 3 splenic injury. Neurosurgery evaluated him upon arrival to the ICU. How is intracranial pressure monitored? The preferred method for ICP monitoring is with an external ventricular drain. This allows the dual function of monitoring ICP as well as allowing to treatment of elevated ICP via drainage of cerebrospinal fluid (CSF). What is a normal value for ICP? Normal ICP is <20 mmHg and treatment is recommended for sustained ICP >22 mmHg. Neurosurgery places an external ventricular drain. His opening pressure was 32, and his ICP ranges from 25-32 over the next few hours. He was in reverse Trendelenburg, and he was adequately sedated. His repeat head CT was unchanged. He had CSF drainage via his EVD. He was given 2 boluses of hypertonic saline. His ICPs improved, and were sustained at 18-20 mmHg. He develops hypotension, with systolic pressures in the 80s. What are some of the possible etiologies for hypotension, and how would you evaluate/ treat the various etiologies? Bleeding from his spleen→ urgent splenectomy. Hypotension is detrimental to TBI. Side effects from sedation medication→ decrease dosages or switch therapeutic agents, implement other treatment strategies Evaluation and Management of Traumatic Brain Injury The goal of the initial management of TBI is the prevention of secondary brain injury. Avoid hypotension and hypoxemia Target normal pulse oximetry, normal PaCO2 (35-45 mmHg) and PaO2 (≥100 mmHg), normal blood pressure (SBP ≥100), normal electrolytes, normal temperature, platelets >75K, hemoglobin >7 g/dL.[1] Treat pain and provide sedation as appropriate. Optimize patient positioning to promote cerebral venous drainage- elevate the head of the bed and ensure the cervical collar or endotracheal tube support is not too tight. Monro-Kellie Doctrine[2] Inside the bony skull, there is brain tissue, blood and cerebrospinal fluid. Increase in any one of these (tumor, hemorrhage, edema) requires a compensatory decrease in one of the other substances in order to maintain normal intracranial pressure (ICP). ICP rises when compensatory mechanisms fail. Elevated ICP leads to decreased cerebral perfusion pressure (CPP). CPP is the difference between mean arterial pressure and intracranial pressure, and serves as an additional measure of adequacy of cerebral perfusion [CPP= MAP – ICP]. This is similar to the concept of abdominal compartment syndrome- when intraabdominal pressure increases above a threshold, there is decreased organ perfusion. Initially, the brain is able to autoregulate and maintain cerebral blood flow (CBF) across a narrow range of CPP, but this compensation is also limited, and CBF decreases as CPP falls. The general target for CPP is ≥60 mmHg, but note that this may vary if cerebral blood flow autoregulation is impaired. Monitoring intracranial pressure (ICP) is not independently associated with improved outcomes. It does not replace serial neurologic exams. Clinical decision making based on the neurologic exam, the ICP, CT imaging and any other relevant information is the key to improving outcomes. There are several patient scenarios that should prompt consideration of ICP monitoring.[1,3] GCS ≤8 + structural brain injury on head CT GCS >8 + structural brain injury on head CT + high risk for progression (large/ multiple contusions, coagulopathy Severe TBI with a normal CT scan + at least 2 of the following- age >40 years, unilateral or bilateral motor posturing, or SBP <90 mm Hg. Progression of brain injury on repeat CT imaging Patients who require urgent surgery for extracranial injuries Clinical deterioration There is a tiered approach to treating elevated ICP.[1] At each tier, patients should continue to have close neurologic exams as well as interval repeat CT imaging of the head to rule-out the progression of hemorrhage. Tier 1- ensure optimization of analgesia and sedation, elevate head of bed, intermittent drainage of CSF. Tier 2- hyperosmolar therapy- mannitol or hypertonic saline. Consider advanced monitoring, including assessment of cerebral autoregulation and other markers of cerebral oxygenation. If utilizing advanced monitoring, consider hyperventilation to PaCO2 30-35 as long as cerebral oxygenation is maintained. Paralysis with neuromuscular blockade. Tier 3- decompressive craniectomy is a potential salvage therapy- may be associated with decreased mortality, but no improvement in neurologic outcomes.[4,5] Continuous infusion of neuromuscular blockade if there is a response to the test dose in Tier 2. Consider Barbiturate coma. Hypothermia and hyperventilation are no longer routinely recommended. Hyperventilation therapy can be used as a bridge to additional interventions. A study of hypothermia in severe TBI has shown no improvement in early neurologic outcome.[6] References ACS Committee on Trauma. American College of Surgeons Trauma Quality Improvement Program. Best Practices in the Management of Traumatic Brain Injury. 2015 Jan. Wells AJ et al. The management of traumatic brain injury. Surgery (Oxford). 2021;39(8):470-478. Carney N et al. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery. 2017 Jan 1;80(1):6-15. Cooper DJ et al. Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med. 2011 Apr 21;364(16):1493-502. Cooper JD et al. Effect of Early Sustained Prophylactic Hypothermia on Neurologic Outcomes Among Patients With Severe Traumatic Brain Injury: The POLAR Randomized Clinical Trial. JAMA. 2018;320(21):2211-2220 Sahuquillo J, Dennis JA. Decompressive craniectomy for the treatment of high intracranial pressure in closed traumatic brain injury. Cochrane Database Syst Rev. 2019 Dec 31;12(12):CD003983 Previous Next

Stereotype of a Surgeon Heartless with a God Complex < Back Stereotype of a Surgeon Abrasive, intimidating, self-confident, egotistic, stubborn, arrogant, difficult to work with, aggressive, competitive, and domineering, technically masterful, astute, energetic, and precise.(1) These are just a few of the adjectives that have been used to describe surgeons. The top Google autocompletes for the phrase "why are surgeons…” include arrogant, rough, rude, important, jerks, mean, cold, weird. There is a balancing act between the need to demonstrate confidence while maintaining our humanity and our humility. We wield sharp instruments, and we ask our patients to trust us to fix them while they lay naked and exposed, anesthetized, and vulnerable. So how do we reconcile these seemingly opposing characteristics? How do we show strength, leadership, and confidence in our decision-making and skills and also develop a rapport with patients and families? How do we show our patients that we will be with them to celebrate their recovery and stand by them in the face of complications and setbacks in their recovery? Effective communication is key to relationship building. In general, surgeons are not known for their stereotype that surgeons don't have the best bedside manner. "As a group, surgeons are not well known for their bedside manner."(2) We (usually) operate on completely unresponsive patients, so the stereotype that we don’t like talking to patients is not illogical. This stereotype extends to anesthesiologists. While this is a satirical representation, there is a kernel of truth in the idea that most don’t go into specialties that frequent the OR to spend MORE time talking to patients. "While poor manners aren't commonly accepted in most professional circles, representations of surgeons in popular culture often link technical prowess with rude behavior, and some surgeons have even argued that insensitivity can be helpful in such an emotionally strenuous profession."(2) I probably spend more time talking to patients and their families than the typical surgeon. I find these personal interactions to be truly remarkable. During my training, I developed my style for communication. When I share information with a patient and their family, I treat them as if it were my family member. Based on my perception of their interest in detail and my direct explanation that I will share as much or as little as they like, I tailor my interaction with each new encounter. I believe in full disclosure, including admitting when I don’t have the answers. My training has given me the confidence to admit when I need more information or plan to consult with a colleague. Some might see my willingness to admit imperfections as a sign of weakness. While I didn’t develop my practice regarding disclosure with the express intention of avoiding legal consequences, poor communication and lack of empathy are commonly cited in malpractice suits.(3) So besides the intrinsic benefit of developing respectful interactions with patients, the extrinsic factor of avoiding the courtroom is powerful. A study published in 2019 found that surgeons are regarded as high in warmth and competence, relative to other non-medical occupational groups,(4) in contrast with the stereotype that we lack social skills. The study also noted that female surgeons received higher warmth ratings than male surgeons, while male surgeons received higher competence ratings than female surgeons. It is not an easy task, but building trust with our patients requires us to instill confidence while maintaining our humanity. 1. Logghe HJ. History of Medicine: The Evolving Surgeon Image. AMA J Ethics. 2018;20(5):492-500. 2. Neilson S. When Surgeons Are Abrasive To Co-Workers, Patients' Health May Suffer. 2019 Jun. NPR. 3. Huntington B. Communication gaffes: a root cause of malpractice claims. BUMC Proceeding. 2003;16:157–161. 4. Ashton-James CE. Stereotypes about surgeon warmth and competence: The role of surgeon gender. PLoS ONE 14(2): e0211890. 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

12 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

How not to lose everything < 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

11 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

Surgery trainee education. Trauma surgeon. Acute Care Surgery. Collaboration Interested in being a guest contributor? Any suggestions and contributions will be promptly reviewed and added to the appropriate page/ subpage. The contributor will be noted on the website- you can choose if you want your name or Twitter handle or whatever other identification you would like (or none at all if you would like to be anonymous). Content currently under development. Note- this list is NOT all-inclusive. Database of clinical vignettes in key topics of trauma, critical care and emergency general surgery. Focused on more complex scenarios (ie not run-of-the-mill appendicitis)! Please check out the vignettes I currently have to get an idea of what I’m trying to create- and reach out with any suggestions or cases. Literature reviews - deep dives, high-yield articles, etc Procedural or skill tutorials (pre-peritoneal packing, using the ultrasound in critical care, reading a chest x-ray). Each tutorial is followed by a list of primary sources, encouraging readers to pull information from multiple references. If there is any particular procedure or skill that you would like to create a tutorial for, or something that is currently on the website that you would like to enhance (for example, more advanced ultrasound techniques or ventilator settings), please feel free to reach out with suggestions! There is a wide array of other content that you can add to as well. Note templates Recommendations on networking opportunities Recommendations on social media accounts to follow Educational resources (textbooks, journal articles, training courses, web based open access medical education) Please send me an email (form at the bottom of the page) or contact me on Twitter @doc_on_the_run if you have any questions or want to submit something.

Surgery trainee education. Trauma surgeon. Acute Care Surgery. FAQs Why did you make this website? Over these years of learning about the practice of surgery, I've also learned a lot about myself. I am not an expert, and I did not follow a typical pathway- but I have some knowledge and resources to share. As I transition into my new Acute Care Surgeon role after 17 years in training, I'm pausing to share my experience, tips for success, and random nuggets of wisdom. This will be a work in progress, and I look forward to seeing how it evolves. My goal is to share my experience and knowledge in the hopes of helping those who desire to follow this path. But why do we need another medical education website? There are so many good resources already... There are endless ways to explain clinical concepts- pictures, text, analogies, clinical cases, podcast discussions of cases or principles, review articles, etc. There are also different learning styles. When I was trying to grasp advanced ventilator management, I read basic critical care textbooks, a book dedicated solely to ventilator management, and various websites and journal articles. This website is another way to interact with the information. Hopefully you will understand some of the concepts in a new way that helps you remember and apply them in clinical scenarios. In addition, I have also tried to create a comprehensive collection of all the useful resources I know, like apps and open access medical education resources (websites, clinical guidelines, etc) in one place for trainees to What does Doc on the Run mean? The summer before my last year of medical school was the start of my running career. My focus was enjoying the outdoors, not pace or distance. During my residency, I met someone who helped me refine my running. I started timing myself, training, and racing. Within a year or two, I pushed through personal barriers to become a "runner." My first half marathon was on Thanksgiving in my third year of surgical residency. I am at the end of my formal training, I am now an Acute Care Surgeon. As a surgeon, there are numerous factors that I can't control. It's fast-paced, demanding, and dynamic. I enjoy the organized chaos and high-stakes cases. Running is key to my work-life balance. Unlike in the operating room or the trauma bay, I have control over most aspects of my runs- pace, distance, route, and thoughts. It's not chaotic- it's basically the polar opposite of my work. During the day, my mind is going a million miles an hour. When I run, everything becomes clearer- I can solve problems, mull over ideas, or process dilemmas. And perhaps the most concrete impact is the runner's high that I enjoy after finishing. I have continued to run 10Ks, 10 milers, and the occasional 5K or 15K. I have learned more about the science of running (HR training zones, different paces for tempo/ interval/ long runs/ short runs) and I've learned how to adapt training schedules to fit my life. Unfortunately, I have suffered my share of injuries, including most recently nerve impingement in my foot. While I may have scaled back, running will always be part of my identity. Did you really build this website yourself? Yes, I did. No, I didn't do all the intricate coding by myself. But I did design, format, and create the content. So are you a computer/ technology guru? Whatever I know about technology, I learned from my brother and from spending many hours researching problems online. While my parents might consider me an expert, I literally just search online to solve most issues. When I get to the end of the internet and still haven't found the solution, my next step is Apple tech support (obviously only if the problem is with my iPhone or Mac). What did you learn while making this website? - Formatting the working space on a website - URL redirect - Domains and subdomains - Search engine optimization (SEO) - Establishing custom domains - Which text/ background colors are easiest to read - Anchors If you weren't an Acute Care Surgeon, what would you do? I'd be a chef. I love cooking! Is there anything that is overwhelmingly gross in your job? I have had almost every body fluid on me- stool, urine, blood, etc. So very little grosses me out. But I can't stand oral or nasal secretions (aka saliva, slobber, snot, etc.).

< Back Ultrasound: Cardiac Exam Purpose: identify possible causes of hemodynamic instability, respiratory distress, assessment of volume status. Probe The phased array can be used for the entire exam. The curvilinear can also be used for the subxiphoid and IVC views. Views There are 4 basic views, including the parasternal long axis, parasternal short axis, the apical four chamber and the subcostal view. Additionally, the inferior vena cava can be visualized. Cardiac ultrasound is more challenging to learn than most other ultrasound studies, because probe usage (position, angle, rotation, translation, etc) have drastic impact on visualization. It’s necessary to understand what is shown in each view, so take time reviewing these so you can have a better appreciation for what you are seeing when you perform a study on a real patient. One recommendation, if it is difficult to visualize the heart, moving the patient into the lateral decubitus with their left side down can significantly improve visualization as the heart is closer to the chest wall in this position. For video and pictorial explanations of the views, please refer to these sites. Basic Cardiac Views, #1 Basic Cardiac Views, #2 Findings Gross abnormalities- decreased ventricular function, arrhythmias Profound hypovolemia Small hyperdynamic left ventricle with end-systolic collapse Inferior vena cava- assess volume status, either static measurement of diameter or calculation of collapsibility (>50% correlates with volume responsiveness). Respiratory variation (collapsibility/distensibility index). Takotsubo cardiomyopathy Akinesia of the apical and mid-ventricular segment, hypercontractile basal segments. Apical sparing (dilated). Acute cor pulmonale Respiratory disorder→ pulmonary hypertension→ right heart failure. Dilated right heart. Cardiac tamponade Effusion with end-diastolic collapse of the right atrium, effusion in front of the aorta Pulmonary embolism Free-floating thrombus in the right ventricle or pulmonary artery; right ventricular dilation/ systolic dysfunction; septal bowing into the left ventricle; dilated IVC without inspiratory collapse. Most sensitive/ specific indirect sign- right ventricular apical sparing (McConnell's sign). References Guidelines for Performing a Comprehensive Transthoracic Echocardiographic Examination in Adults: Recommendations from the American Society of Echocardiography Previous Next