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1st day in radiology: your right is your left, your left is your right Radiologic Dyslexia < Back 1st day in radiology: your right is your left, your left is your right I have recently coined a new phrase. While showing my mom a picture, pointing out someone she had never met before, I commented, "he's the one on the right." Funny story, though- he was actually on the left side of the picture. I had to pause while I talked to my mom and reassure her that I know the difference between my right and my left. While scrolling through Twitter the other day, I was reviewing a question posed about an abdominal x-ray. Another Twitter user added a helpful hint by indicating "the right side of the circle" when pointing out an abnormality. I predicted he meant anatomical right (meaning the image's left side) based on my interpretation. We chuckled about the discrepancy between radiographic laterality and left-right differentiation in real life. I decided to designate this mix-up "radiologic dyslexia." Feel free to use this in the appropriate context! Previous Next

< Back Vent Mgmt #4: All Together Choosing a mode Controlled- patients who aren't generating breaths. PC, VC. Most common mode at initiation of MV. SIMV- patient generating some breaths, but still needs significant mechanical support. Spontaneous- not frequently used at initiation, but can be used for patients with airway obstruction and preserved lung function. How to set initial parameters TV (6-8 mL/ kg predicted body weight) [lung protective ventilation] RR 10-14 FiO2 often start at 100%, but quickly weaned unless severely hypoxic Inspiratory:expiratory ratio typically 1:2 Flow- typically set @ 60L/min, can increase if the patient is in distress or has a high minute ventilation How to adjust parameters based on arterial blood gas results Low PaO2 (low arterial oxygen content)- increase FiO2, increase mean airway pressure Markedly elevated PaO2 (hyperoxia)- decrease FiO2 Low PaCO2 (low arterial carbon dioxide concentration)- decrease TV or RR High PaCO2 (high arterial carbon dioxide concentration)- increase TV or RR *For more details, check out these resources: Lectures: Critical Care: Respiratory Failure Lectures: Critical Care: Vents Other principles of mechanical ventilation VAP bundle- elevated head of bed, oral care Daily awakening and spontaneous breathing trials Previous Next

< Back Free Fluid in the Abdomen A 62-year-old male presents following a motor vehicle collision in which he was an unrestrained driver. He was intubated in the trauma bay for decreased mental status. A focused assessment with sonography for trauma (FAST) was performed, which did not reveal intra-abdominal fluid. Computed tomography (CT) of the head demonstrated minimal intra-cranial injury. CT of the abdomen and pelvis (see below) revealed decreased blood supply to the left kidney, small irregularity of the splenic contour, and a moderate amount of free fluid in the abdomen and pelvis. Hounsfield units are consistent with simple fluid. CT of the abdomen and pelvis https://video.wixstatic.com/video/3b6ff6_b03419943e9941d281c3d8f0b800e37f/480p/mp4/file.mp4 What is the differential diagnosis for the free fluid in the abdomen? Free fluid due to trauma can be urine, enteric contents (bowel injury with spillage of succus) or blood. It is possible to have fluid present prior to the trauma, such as ascites from chronic liver disease. In this case, the free fluid in the abdomen had characteristics of “simple fluid,” based on Hounsfield units, suggesting that the fluid was not blood. In females, free fluid in the pelvis can be normal (physiologic fluid). However, free fluid is NOT normal in a male, and it's concerning for hollow viscus injury. What are the possible causes of decreased blood flow to the kidney? The renal artery can be injured in blunt trauma. Blunt injury can disrupt the layers of the artery wall, leading to thrombosis and decreased blood flow beyond the injury. He was admitted to the intensive care unit. A foley catheter was placed and demonstrated pink-tinged urine [NOT frank gross blood/ clots]. What are the possible causes of blood-tinged urine? Bloody urine indicates a traumatic injury to the genitourinary tract, anywhere from the kidneys down to the urethra. A CT cystogram was performed, which did not reveal any extravasation of contrast from the bladder. CT Cystogram https://video.wixstatic.com/video/3b6ff6_119074429b224cc98677d4f101fef666/480p/mp4/file.mp4 Next steps? Based on an unreliable physical exam and a normal CT cystogram, it is necessary to rule out bowel injury. The patient was hemodynamically stable and had normal laboratory values. He remained with a decreased mental status, and therefore serial abdominal exams were not a viable management plan. The patient was taken to the operating room and underwent diagnostic laparoscopy. His small bowel, colon, and mesentery were examined in there entirety and found to be completely normal. There was a small amount of clear thin fluid in the pelvis, but there was no evidence of bile staining or bleeding. After completing the evaluation of the gastrointestinal tract, we repositioned the patient in Trendelenburg. The pelvis was inspected, and it was quickly apparent that the patient in fact had a large defect in the dome of the bladder. We elected to proceed with a low midline laparotomy. The bladder was easily mobilized, and the extent of the defect was defined. The edges were grasped, and the defect was closed in two layers with absorbable suture. Postoperatively, we reviewed the preoperative CT cystogram. In retrospect, there was a suggestion of bladder irregularity. We reviewed the CT cystogram with the radiologist and there was no evidence of contrast extravasation. However, the bladder does not appear to have been completely distended with contrast. It is very atypical that a large bladder wall defect was not associated with contrast extravasation, and this highlights the importance and ensuring complete filling of the bladder with contrast. Evaluation and Management of Bladder Injuries Bladder injuries can occur from blunt or penetrating trauma. For example, bladder injuries can occur when blunt force is exerted on a full bladder or in the setting of a pelvis fracture. Diagnosis Gross hematuria is seen in most patients with bladder injuries. Cystography, either using plain x-ray or CT, is the diagnostic test of choice. Management The management of bladder injuries is based on location. Intra-peritoneal injuries require operative management. This is done in two or three layers with absorbable suture. A decompressive foley catheter is left following repair. Extra-peritoneal injuries can typically be managed non-operatively with a foley catheter for 10-14 days. Exceptions include large bony segments protruding into the bladder wall, associated rectal or vaginal injuries, bladder neck injuries, or an associated pelvic fracture undergoing operative intervention to prevent hardware contamination. Current guidelines recommend a cystogram before foley removal, except for the most uncomplicated injuries. Yeung LL et al. Management of blunt force bladder injuries: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2019;86(2):326-336. Previous Next

< Back Fever...pending Evaluation of Fever Previous Next

3 General Surgery Lectures General Surgery .pdf Download PDF • 152.12MB Anorectal .pdf Download PDF • 1.55MB CT Scan and X-ray .pdf Download PDF • 564KB Vascular .pdf Download PDF • 13.57MB Suture .pdf Download PDF • 4.94MB

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

< Back AKI...pending ​ ​ ​ ​ Previous Next

< Back Pneumonia...pending ​ ​ ​ ​ Previous Next

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

< Back Gunshot Wound to the Leg ​ ​ ​ ​ Previous Next