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Overcoming barriers while teaching and being humble as a consultant Tackling the expertise bias < Back Overcoming barriers while teaching and being humble as a consultant Why is it so hard to remember what it was like before you knew the things that you now consider fundamental, basic knowledge? If you are a teacher, which includes school teachers as well as everyone responsible for passing knowledge to others, self-reflection on how you relay information and assess comprehension is paramount. One common challenge is overcoming the "curse of knowledge". The curse of knowledge takes hold and becomes a hurdle when the teacher/ instructor assumes that their audience has the same background knowledge and should be "up to speed" without significant delay. In other words, there are many things you do every day that you consider obvious and second nature. It is exceedingly easy to be quick to judge your trainees for not recalling or readily grasping those concepts. How has this manifested itself in my experience as a teacher in the ICU? Caring for patients with a wide breadth of physiologic derangements is a rich environment for interactive real-time learning. Invasive mechanical ventilation is a perfect opportunity to learn about respiratory physiology. Learning how to pick the right mode/ settings and how to make adjustments to optimize each patient's oxygenation and ventilation (while avoiding further lung injury) is key to good critical care for the patient that requires respiratory support. My understanding of mechanical ventilation was the culmination of many hours and long months/ years spent reading, preparing lectures, tinkering bedside with ventilators, engaging in dialogue with experts, and just immersing myself in the weeds. At some point, and I have no idea when it was precisely, it finally clicked. I didn't become an omniscient guru. But after enough practice, the fundamental concepts finally became solidified in my mind, and managing ventilators has become second nature. Ventilator management is a cornerstone of ICU care. Whenever there are patients that require ventilation beyond perioperative indications, I capitalize on the opportunity to teach. Even though I'm acutely aware of how much work (seemingly endless hours of work) went into learning the finer points of ventilators, it's still hard to remember what it was like before I understood. Please note- this phenomenon is NOT limited to in-person teaching. This barrier can infiltrate lectures, manuscript writing, and a variety of other forms of communication and interaction. Another situation relevant to the medical profession- the consultation with a specialist. If you're on the receiving end of the consult, it can be easy to fall into the trap of assuming everyone should have the same knowledge you have. It's crucial to remember that you are an expert in YOUR field- if the physician calling you had the same knowledge, you would be obsolete. So how do you overcome this hurdle? Here are my suggestions 1. The first step is to acknowledge that your interactions can be impacted by your bias. You know more than your students, or the person that's calling you for a consult. More specifically, you know more about what you're teaching your student and you know more about the clinical situation than the person consulting you. That's why you're the teacher and the consultant. 2. Take time to reflect on how you interact when teaching- do you rapidly become impatient, roll your eyes, reply with condescension or snark, or simply look at your students like they're idiots? Pause in real-time: it doesn't have to be awkward, and I'm sure your audience will appreciate a moment to pause and think. 3. Take the opportunity to put the shoe on the other foot. Reflect on what it was like when you were learning- as an intern struggling to remember how to replete electrolytes, a young resident in the ICU struggling to understand ventilators, or even a young attending struggling in a high-stress operative case. How would you want to be approached/ treated? Previous Next

< Back Pancreatitis UpToDate Patient Education Patient education: Acute pancreatitis (Beyond the Basics) Patient education: ERCP (endoscopic retrograde cholangiopancreatography) (Beyond the Basics) Source: UpToDate Images: Pancreas Anatomy Previous Next

< Back Pain and Anxiety...pending Management of Pain and Anxiety Previous Next

< Back Who Is Our Patient Population? We take care of critically ill and injured patients. Here are just a few examples of the different patient scenarios we manage. We are available 24 hours a day, 7 days a week. Therefore, we often receive consults for various other surgical disease processes outside of what is listed here. Trauma Penetrating wounds from gunshot wounds, stabs, or assaults from any material that breaks the skin and causes bleeding or significant tissue damage Blunt injuries from falls (roof, ladders, etc.), motor vehicle accidents, bicycle accidents, pedestrians struck by vehicles. Non-accidental injuries (abuse, inter-personal violence) Surgical Critical Care Critically ill trauma or emergency general surgery patients. Patients undergoing complex or high-risk surgical procedures or requiring intensive care unit (ICU) admission. Complications from procedural interventions. Intra-abdominal catastrophes. Airway emergencies- patients who are unable to be intubated and require a surgical airway. Emergency General Surgery Appendicitis, Cholecystitis, Diverticulitis. Bowel ischemia or bowel obstruction. Soft tissue infection- necrotizing soft tissue infection. Surgical airway or enteral access- tracheostomy for ventilator dependency and percutaneous endoscopic gastrostomy (PEG). Previous Next

< Back Unusual Case of Peritonitis A 23-year-old male presents to the ED with several days of abdominal pain. He is otherwise healthy and denies any other symptoms. On exam, he has diffuse peritonitis, but no other obvious findings. He is tachycardic with a heart rate in the 110s-120s. His blood pressure is 100s/60s. No significant medical or surgical history. No remarkable events recently. He had plain films of his chest and abdomen. Plain film of the chest and upper abdomen What's going on? Differential diagnosis? Perforated hollow viscus- gastric or duodenal ulcer, bowel obstruction leading to perforation, procedural complication (EGD, ERCP). On further questioning, the patient endorses a recent soccer game during which he blocked a goal and was hit in the stomach. Unsure if it was the soccer ball or a kick to the stomach. He then had a CT of his abdomen and pelvis. CT of the abdomen and pelvis, representative slices What's going on? Diagnosis? Intervention? Free air (pneumoperitoneum) and free fluid are consistent with a perforated hollow viscus. No clear source on the CT. This requires abdominal exploration. We proceeded with exploratory laparotomy. Found liters of succus. There was a single perforation of the small bowel that was resected and anastomosis was performed. The abdomen was closed and a drain was placed. Intraoperative Findings Management of Peritonitis from Perforated Hollow Viscus The hollow viscus refers to the gastrointestinal tract from the esophagus to the rectum. Pain associated with hollow viscus perforation is classically acute onset, constant, severe, and worse with movement. The peritoneal lining of the abdomen becomes inflamed in reaction to the leaking enteric contents. This is a surgical emergency. The diagnosis can be made with the visualization of pneumoperitoneum on an upright chest x-ray (lucency under the diaphragm). A patient with peritonitis and free air requires surgical exploration. A CT scan can help identify the underlying pathology, but is not mandatory and should not delay operative intervention. Non-operative management is reserved for the patient with a sealed perforation (example- retroperitoneal duodenum) or a patient who is a prohibitively high-risk operative candidate (example- patient on palliative or hospice care). Cultural differences Not all cultures have adopted the practice of Western medicine. In some cultures, people still seek advice and medical care from traditional healers. Unfortunately, this can delay treatment if a patient requires operative intervention. Some of the treatments provided by traditional healers can also lead to further injury. This patient with a small bowel injury was seen by a traditional healer several times before he was finally brought to the hospital. The marks on his skin are the result of a practice of cutting the skin to heal the cause of his abdominal pain. Another patient was brought to the hospital for a severe infection of his genitalia. By the time he came to the hospital, his infection was so extensive that he required a debridement of a large portion of the skin in his perineum. He had been seeing a healer who was treating him with a topical solution that had essentially burned his skin, so in addition to the underlying infection, he had severe tissue damage. Previous Next

Common Measurement Conversions < Back Kitchen Hacks #3 Common Measurement Conversions Powdered Milk Reconstitution Use volume of water equivalent to desired milk volume. 1 Cup Milk= 3 Tbsp Powdered Milk= 45 mL 3/4 Cup Milk = 2.25 Tbsp Powdered Milk 2/3 Cup Milk = 2 Tbsp Powdered Milk= 30 mL 1/2 Cup Milk = 1.5 Tbsp Powdered Milk 1/3 Cup Milk = 1 Tbsp Powdered Milk= 15 mL 1/4 Cup Milk = 3/4 Tbsp Powdered Milk Measuring Spoon Conversions 1/2 tsp= 2.5 mL 1 tsp= 5 mL 1 + 1/2 tsp= 1/2 Tbsp= 7.5 mL 2 tsp= 10 mL 3 tsp= 1 Tbsp 6 tsp= 2 Tbsp= 1/8 c Liquid Measurement Conversions 1 fluid ounce= 2 Tbsp= 6 tsp 2 fluids ounces= 4 Tbsp= 1/4 cup 2+2/3 fluid ounces= 5 Tbsp + 1 tsp= 1/3 cup 4 fluid ounces= 8 Tbsp= 1/2 cup 6 fluid ounces= 3/4 cup 8 fluid ounces= 1 cup 16 fluid ounces= 2 cups= 1 pint 4 cups= 2 pints= 1 quart 4 quarts= 1 gallon Substitute dry for fresh spices 1:3 of dry:fresh 1 tsp dry= 1 Tbsp fresh Previous Next

< Back Chicken Enchiladas in Sour Cream Sauce Ingredients 10 small soft flour tortillas 3 Tbsp flour 2 c chicken broth 1 c sour cream 2.5 c shredded cooked chicken 3 c shredded Monterey Jack cheese 3 Tbsp butter 4 oz can diced green chillies Instructions 1. Preheat oven to 350 degrees 2. Combine shredded chicken and 1 cup of cheese. Fill tortillas with the mixture above and roll each one then place in a greased 9x13 pan. 3. Melt butter in a pan over medium heat. Stir flour into butter and whisk for 1 minute over heat. 4. Add broth and whisk together. Cook over heat until it's thick and bubbles up 5. Take off heat and add in sour cream and chilies. Be careful it's not too hot or the sour cream will curdle. 6. Pour mixture over enchiladas and add remaining cheese to top. 7. Bake in oven for 20-23 minutes then you will want to broil for 3 minutes to brown the cheese. The roux, with sour cream and green chilies added Previous Enchiladas covered with sauce Cooked and broiled to brown the cheese Next

3 < Back Acute Care Surgery Clinical Guidelines EAST Practice Management Guidelines. Evidence-based guidelines developed and published by EAST. Covers EGS, ICU, trauma, and injury prevention. SurgicalCriticalCare.Net . Evidence-based guidelines from Orlando Regional Medical Center. Vanderbilt Trauma and Surgical Critical Care Practice Management Guidelines. Evidence-based guidelines developed by Vanderbilt. Covers trauma and surgical critical care topics. Evidence-Based Decisions in Surgery. This does require membership with the American College of Surgeons. General Medical Information UpToDate. The name says it all- evidence-based recommendations based on the most current literature. Subscription required. Previous Next

< Back 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 Vent Mgmt #5: Weaning When is the patient ready to start ventilator weaning? Resolution of pathology resulting in the need for mechanical ventilation Able to assess mental status (ie can the patient follow commands) Hemodynamics and respiratory physiology is optimized (ie ABG normalized or returned to patients baseline, and normalization or stabilization of cardiac function) Minimal ventilator settings (FiO2 21%, PEEP 5) NOTE: Even if there is no immediate plan to extubate, sedation holiday and spontaneous breathing trials should still be performed [unless there are specific contraindications] Spontaneous breathing trial Spontaneous mode of ventilation (such as pressure support or CPAP) with 5-8 cm H2O support during inspiration (basically overcoming the force required to breath through the small diameter of the ETT) Failing SBT Hemodynamic instability (hypotension or hypertension, tachycardia or bradycardia) Agitation Respiratory instability (hypoxia, inadequate tidal volume, tachypnea or decreased respiratory rate) Extubation parameters- how do we know if the patient is ready to be liberated from the ventilator? Able to generate adequate minute ventilation Rapid shallow breathing index (RSBI)- RR/ TV. High respiratory rate (rapid) and low tidal volume (shallow) are more suggestive that a patient isn't appropriate for extubation. Value <105 suggests the patient will successfully extubate. This is also known as the Tobin index.[1] Negative inspiratory force (NIF)- the patient's ability to generate negative pressure with inhalation. Cuff leak- ability to move air around the endotracheal tube. Not mandatory to evaluate for cuff leak prior to extubate EXCEPT for patients is at high risk for airway edema (traumatic intubation, intubated >6 days, large ETT, female, reintubation after unplanned extubation). Reasons for failed ventilator weaning Prolonged hospitalization and associated weakness Hypophosphatemia Primary process requiring mechanical ventilation is unresolved Passed SBT...but failed ventilator liberation? Excess secretions/ inability to cough Cardiac instability related to physiological changes with loss of positive pressure (specifically decrease in intra-thoracic pressure leading to decreased cardiac output) Tobin Index. Yang KL, Tobin MJ. A Prospective Study of Indexes Predicting the Outcome of Trials of Weaning from Mechanical Ventilation. N Engl J Med. 1991 May 23;324(21):1445-50. Previous Next

Gadgets and Tools < Back My Favorite Things Gadgets and Tools Packing and Travel These Hopsooken packing cubes make organizing your suitcase a breeze. These noise-canceling headphones effectively drown out the rumbling noise of airplanes at a reasonable price. The Patagonia Black Hole Duffel . Multiple sizes available. Very spacious. Easily converts to a backpack when traveling for easy carrying. Therma-Rest compressible pillow from REI Quick Dry Towel from REI Cleaning Products Goo Gone - for removal of excess sticky residue. Greased Lighting - great for stain removal. It can be purchased at Lowes/ Home Depot. Kitchen Storage containers for baking ingredients. These wide-mouthed containers let you pour baking ingredients from their original bags with minimal mess. It’s also very easy to use a scoop directly into the containers when baking. This is a perfect bread box ! When I leave a loaf of bread in its original package, it gets moldy pretty quick- but if I put it in this box, it lasts much longer. Bakers Rack . My current kitchen has much less cabinet space than what I have grown accustomed to, so I sought out a solution to store my baking supplies that take up my counter space. Now my bread maker, mixing bowls, large metal colander, and rolling pin no longer hide above the fridge or clutter my counters. Writing Accessories A hand-held non-electronic datebook . After years of relying on electronic resources to maintain my schedule, I finally made the switch to a device that allows me to create/ maintain a schedule, both weekly and monthly formats. Also has blank pages at the back, perfect for lists, notes, etc. Frixion Erasable pens “We've all had a shower thought or two…They're the miniature epiphanies that occur when your brain is occupied with doing something else, but suddenly you realize that you've come up with a totally unique way of thinking.” And sadly, once we step out of the shower, the great idea seems to vanish. Thankfully, someone developed this notepaper that doesn’t fall apart in the shower! A roll of self-adhesive whiteboard paper to post to your wall, your fridge, your mirror, wherever. Handy in the kitchen- plan meals, add items to put on your grocery list when you discover you’re running low or just write reminders. My favorite highlighters when writing notes. They aren’t too heavy, so they don’t bleed or run. They are dual-tipped, with a broad highlighter on one end and a narrower tip for writing on the other end. My favorite pen . Fine tip to allow precise, small writing. Trello - a user-friendly free application with multiple functions. I use it to store frequently used documents to allow quick reference. It is also a very convenient way to create and manage lists among teams so everyone has easy access. Check it out, you might find it useful. Things for the Ladies I don’t wear many thin garments or revealing necklines, so I don’t often have to struggle to find a bra that remains concealed. However, on the rare occasion that I wear a dress or top that isn't conducive to wearing a bra, these reuseable cover-ups are incredibly handy for maintaining decency. If you're interested in making the transition from disposable monthly products, check out this product . This is the only one I've tried, so I can’t compare them, but it's worked well for me. Lume Deodorant . Doesn’t stop sweating, but eliminates odor. Highly highly recommend. If you find yourself having to unclog the shower drain with clumps of hair, you might want to check out the Tub Shroom . Previous Next

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