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Maintaining our humanity in the clinical environment Comfortably Numb < Back Maintaining our humanity in the clinical environment If you are working in an intensive care unit, your patients will frequently be intubated and/ or sedated. The ICU can be very dehumanizing, and it is easy to forget that patients are human beings with family and friends that love them. Adherence to critical care guidelines and following protocols is important. But while we are providing the highest level of care based on evidence, we must not ignore the humanity of our patients. There is a missing link that isn’t routinely taught in school or nurtured in training and isn’t encouraged when it is performed. The human connection, treating a patient like a person. Treat your patients as if they were your family member. Basic human decency supports the practice of avoiding derogatory conversations in the presence of patients. I have witnessed more than a handful of incidents of medical personnel discussing other patient scenarios in the presence of other patients. HIPAA laws aside, generic simple conversations are likely unavoidable (“hey the patient next door needs his pain medication…”, “is room 7 ready for radiology…”, etc). However, I have witnessed providers speaking about a brain dead patient who was being evaluated for organ donation in the presence of another patient. Speaking about death and organ donation in the room of a critically ill patient is unacceptable. Mentioning derogatory things about patients in the operating room is unacceptable. My personal opinion is that negative things should be avoided in general. I don’t mean that real problems should be swept under the rug. But in my opinion, extraneous negative remarks have no place in a patient's room. A few thoughts. 1. Don’t lose your humanity. Treat all patients as if they were your loved one (family, friend, whatever fits that category for you). If you catch yourself slipping into a routine of just seeing the procedures and diagnoses, I urge you to engage in intentional self-reflection. 2. Treat all patients as if they can hear and sense everything. I am not a proponent of the occult or the metaphysical, and I don’t believe in jinxes- I don’t believe that mentioning bad prognoses makes them more likely to occur. However, I believe that most patients who are intubated and sedated are aware, on some level, of their surroundings. There are plenty of reports of patients recalling stressful experiences from their time in the ICU. I don’t think we will ever know what they can hear or sense, or how it impacts their emotional and physical well-being. Therefore, I strongly advocate for treating all patients as if they can hear and sense everything. 3. Try to imagine what you would want if you were in the patient's position. Imagine you can’t talk, you’re in pain, you have an itch you can’t scratch, your eyes are stuck shut from eye crust that you can’t wipe away, your mouth and throat feel like sandpaper, you don’t have your glasses or your hearing aids, you have no idea where you are or what day it is, etc etc. Now imagine you are slowly waking up as your sedation medicine wears off. You have people pinching you and yelling at you to open your eyes. Compare that to hearing a calm steady voice in your ear, speaking encouraging words, explaining that you are in an ICU, you have a breathing tube in place, you’re safe, your medical team is waking you up to see if you can breathe on your own and get the tube out. I’m not suggesting that this practice will eliminate agitation when a spontaneous awakening trial is performed. But just imagine the difference of being reoriented when you have no control instead of being shouted at and told to open your eyes. Imagine someone taking a wet washcloth to your eyes to remove the crust, allowing you to open your eyes for the first time in days. It’s not something you’ll learn in medical school. And it shouldn’t be revolutionary…but just imagine the difference in the patient's perspective and understanding of their situation. Previous Next

Caring for soldiers in the deployed environment Austere Damage Control Surgery < Back Caring for soldiers in the deployed environment “Our general attitude around here is that we want to play par surgery. Par is a live patient.” Several years ago, when I was preparing to apply for trauma fellowship, someone called me a meatball surgeon. I thought it was a lame nickname that meant our job was mindlessly easy. For the first time ever, I recently Googled meatball surgery. The term "meatball surgery" was used to describe the damage control interventions performed in MASH. Yes, I am proud to say I am a meatball surgeon for our soldiers. Telling me I save lives is a compliment…not an insult. Meatball Surgery Military surgeons are frequently deployed to far forward environments to perform damage control surgery- stopping bleeding, stopping gross spillage of bowel contents, stenting vascular injuries, etc. This allows the patient to be evacuated to the next level of care. The goal is NOT definitive repair of injuries. All general surgeons deploy in this role- so maintaining trauma operative skills and the skill of "thinking like a trauma surgeon" is crucial. This is being increasingly provided between deployments with skills labs and military civilian partnerships. There is still a significant gap between recommended case volume and actual case volume. Recently, the suggestion to train non-surgeons to do “just a bit of damage control surgery" in the deployed environment has been proposed in several forums, including on social media. Short version: “You can’t convince me that pelvic packing, laparotomy, vascular control, thoracotomies are difficult.” Why is this a problem? As mentioned, its hard enough to train our general surgeons well-trained to perform in this environment. It would take significant changes in our current training rhythm to get Pas and non-surgeons adequately proficient to provide this skillset. It is NOT easy being a trauma surgeon. A lot of surgery residents are familiar with the oft repeated quote, "you can teach a monkey to operate". It's not meant to insult trainees and compare them to monkeys. It's meant to explain that the difficult skill of being a surgeon is the judgment to decide who needs surgery, what surgery is needed and how to anticipate the next step. There are many algorithms in surgery. They are excellent guides to optimal patient care. But they all have the same caveat (although some might not state it as explicitly)- they are not to be used in isolation, but instead in the setting of sound clinical judgment. To gain this expertise, surgeons endure 4 years of undergraduate education, 4 years in medical school, 5-7 years of surgical residency, and 1-2 years of fellowship. And even after I spent all this time training, I’m still not done learning this art. If you say these are "not difficult” procedures, I encourage you to complete a general surgery followed by a trauma fellowship. The military actually does need more trained trauma surgeons. But no, I’m not interested in training a non-surgeon to do “just a little bit” of trauma surgery. I can't imagine any trauma surgeon who would be willing to teach a watered down version of our skill to a non-surgeon and sign off that they’re qualified to care for our soldiers. Please don't insult our expertise. I would never presume to be an expert in another persons specialty. This would be similar to suggesting that I can be easily trained to be special forces. Anyone can be taught to shoot a weapon, evade the enemy, decide the best tactical approach, etc. You may say that’s an exaggeration. But it’s the absolute truth. A field surgeon is NOT a surgeon. A brigade surgeon is NOT a surgeon. A flight surgeon is NOT a surgeon. A division surgeon is NOT a surgeon. A battalion surgeon is NOT a surgeon. The Surgeon General is NOT a surgeon. Previous Next

Resolving Patient Concerns Who's my doctor? < Back Resolving Patient Concerns During the course of a day, numerous people walk into a patient's room- nurses, case managers, physicians, APPs, trainees, respiratory therapists, physical therapists, just to name a few. It is easy to see how a patient can lose track of who's who. There are multiple providers on a typical inpatient service, including students, residents, APPs, and an attending physician. Although it's not impossible, it would be a rare occasion for a patient to not be seen by a physician or APP at least once a day (usually more). But multiple times, patients ask their nurse or directly ask their provider why they haven't seen a doctor yet. They may also ask why they hear different plans from different people, or why no one has told them a plan. At first glance, these comments might seem as an indicator that the team caring for the patient isn’t being attentive, isn’t knowledgeable about the patient's current condition or plan, or isn’t a united front. And it's understandable why this would be disconcerting to a patient. So why does it happen and how can you handle it? Some of these comments reveal a misperception (who is my doctor, why does no one come to see me, why is nothing happening), while other comments reveal true instances of confusion or breakdown in communication or that could be avoided (multiple consultants, waiting to talk to the attending, change in plan). Patients can be upset about any of a wide variety of things- untreated pain, prolonged NPO status (nil per os, meaning they can't eat), frustration about prolonged illness or another complication, or restricted activity (patients at risk for falling have to ask for assistance to get out of bed). Patients can also display anger when they are scared. For all of these issues, make sure the patient has the opportunity to verbalize their thoughts and concerns- their initial question may not actually be their real issue. Question #1 Why haven’t I seen my doctor today? When am I going to see the person in charge? A. Background. Patients expect their doctor to be involved in their care. They expect their doctor to examine them, ask them questions, and provide a diagnosis and a plan. They also expect to be able to ask questions and voice concerns to their doctor. B. Why/ how does it happen? Given the wide variety of people who pass through patient rooms, it can be difficult for a patient to identify who their physician is. If the patient feels that nothing is happening or they're still in pain or they haven't had their questions answered, it's natural to ask who the boss is. C. How to respond? Identify your role with the team- whether you're the chief resident, the attending, or even a student or young resident. If you aren't a senior team member, ensure the patient that you will bring their concerns to the attending- and make sure you follow through. If you're the attending or senior resident, your response should be tailored to the patient's demeanor. - If the patient is angry, give them time to express their feelings. - If it's a matter of confusion, it's helpful to take a moment to explain the team structure- the other team members who they see throughout the day are direct extensions of the attending on the service. - If there is a real medical issue that hasn't been resolved, none of the explanations about team structure matter. If you're the attending, convey this to the patient, and make it clear that you will work with them to solve the problem. Question #2 Why does no one know what's going on? Why are you telling me something different than what the other doctor said? A. Background. Patients expect their doctors and nurses to take the best possible care of them, which includes having one unified plan. It would be easy to understand why a patient would be distressed or anxious when they hear conflicting plans or recommendations. B. Why/ how does it happen? Plans are not set in stone in the dynamic field of surgery. - Patients with non-elective surgical issues are at risk of having changes in their plan. New fevers, changes in pain, new laboratory values, or radiographic findings can all lead to an urgent need for intervention, either surgery, a minimally invasive procedure, placing tubes, etc. This doesn't mean that the teammates who spoke to them earlier were wrong- it just means there has been a change. - Patients are often seen by residents, both from the primary team as well as consultant teams. Residents, especially more junior residents, don't have the same authority to tell the patient a definitive plan as the chief resident or attending. They might propose some possibilities, and then tell the patient they'll be back with their boss (common language to refer to their chief resident or attending). Sometimes patients hear one thing and don't understand that it's not the final plan. - In addition, when patients are first seen by the resident, there is often a time delay between the initial patient evaluation and discussion with the attending physician. It can appear that nothing is happening or that the team doesn't know what to do. C. How to respond? - Explaining the team structure and reassuring the patient that they will be updated as soon as possible can alleviate some of the anxiety/ frustration. Explaining a change in plan can be tricky. It's important not to undermine other team members. It's a learning process for trainees- you don't have to make excuses. As the attending, you can reassure that patient that the team members discuss their plans with you and you have the final say in their care. Question #3 Why was my surgery canceled? A. Background. When a patient needs surgery, the operating team makes a plan for their operative day. The patient is made NPO, meaning they can't eat or drink before surgery. They may have their family or friend scheduled to come to be with them on that day. So it's understandable for a patient to be frustrated or angry when they are told their surgery is canceled. B. Why/ how does it happen? Operative cases can get rescheduled or delayed with minimal notice. Even when cases are scheduled, there is always the possibility of another patient needing a more urgent operation. This applies to cases done by the trauma team, as well as cases with subspecialists. The orthopedics team is busier when trauma volume increases, so this puts further strain on OR availability. C. How to respond? The frustration is understandable, so it is helpful to explain why their surgery date has been pushed back (or hasn't been set yet). It's important to NOT "throw them under the bus"- in other words, don't speak ill of other teams. You don't have to go into a big explanation, but it's helpful for the patient to understand because this can alleviate some of their displeasure with the teams, including the consultant teams. It's not a matter of the teams not thinking the patient is important- it's simply triage. Also, try to get a plan as early in the day as possible, so the patient can be allowed to eat if their surgery is postponed. Question #4 Why is nothing happening? A. Background. Patients expect things to happen in a hospital to make them better. B. Why/ how does it happen? A lot of patient care happens away from the patient's bedside. Reviewing labs, imaging, discussing with consultants, performing procedures, phone conversations with nursing and case managers, just to name a few things that happen outside of the patient's room. However, this complaint can be a little more nuanced- sometimes the patient is trying to say they're frustrated by prolonged hospitalization, or they're scared about a complication, or they're worried they won't get back to their life as they had before their injury. C. How to respond? Again, if this is an issue of confusion, sometimes a brief explanation is enough. If there are specific consultant recommendations or a specific test result that is pending, attempting to contact the consultant team or expedite a radiology study in front of the patient is a small way to show the patient that things are happening behind the scenes. But if the patient is frustrated with being hospitalized or scared about surgery or a complication, those explanations won't address their concerns. Those issues require a more tailored response. Question #5 Why can’t I eat? A. Background. Sometimes patients in the hospital are feeling ill enough that they have no interest in eating. But if they still have an appetite, there are sometimes when it’s not safe to eat. B. Why/ how does it happen? Patients can't eat before surgery- specifically, it's dangerous to have food or thick liquids in their stomach when they have sedation medication or paralytics, because there is a risk of the stomach contents coming up into the throat and then going into the airway. So while a patient is awaiting procedural intervention (surgery, minimally invasive procedure that requires sedation), they can't eat. When we are awaiting the recommendations and plan of care from a consultant, we don't allow the patient to eat until we know they don't need a procedure. Besides procedures, patients may have to abstain from eating if they have a problem with their intestines, such as an obstruction or a fistula (abnormal connection from the bowel to the skin). C. How to respond? Apologize, basically. There's not much else to do. Previous Next

The Challenges of Being A Female (Acute Care) Surgeon Are you sure? < Back The Challenges of Being A Female (Acute Care) Surgeon My 17-year journey to become an Acute Care Surgeon started when I applied for medical school in my senior year of high school. I went to a 6-year combined-degree medical school and then completed a 6-year surgical residency. At age 29, I began my practice as a General Surgeon. After 3 years as a Staff Surgeon, during which I had one combat deployment and one medical readiness exercise in Africa, I then chose to complete an acute care surgery fellowship. Our acute care surgery department was comprised of 14 surgeons, only 3 of whom were female. Surgery has historically been a male-dominated specialty, and female surgeons continue to face significant obstacles.(1) There has been a noticeable shift with more females choosing surgical specialties, although they continue to be under-represented in trauma. This can create a sense of rivalry or competition, the need to be seen as equally competent as our male colleagues. On top of the difficulties inherent to surgical training and practice, the constant pressure to live up to expectations can foster stress and doubt. Imposter syndrome, which is "a psychological pattern in which people doubt their accomplishments and have a persistent, often internalized fear of being exposed as a ‘fraud’," can result.(2) Are You Sure This is What you Want to Do? Twelve years ago, during my internship, I was in the process of reapplying for the remaining 5 years of my surgical residency (a phenomenon that was subsequently eliminated from military surgery residencies). As I asked one of the senior (male) surgeons for a letter of recommendation, he discussed the issue with me in the middle of a busy clinic, with other residents and staff present. He asked if I was sure I wanted to do a surgery residency, and he encouraged me to consider other career paths. Thankfully, I did not experience this discrimination from any of my other staff. But I do wonder if there was discrimination of omission...were my male co-residents provided encouragement or advantages that I was not afforded? In my small residency, with a total of 18 residents, we had a total of 5 females during my first year, including another female intern. I felt encouraged that 2/3 of my class was female, but this was the exception and not the rule. Eight years ago, during my surgical residency, I was at a very busy Level 1 trauma center. I can't recall the exact ratio of male to female surgeons, but I know women were in the minority. During a non-emergent trauma case, there was a product representative in the room. During a casual conversation, he was clarifying who was the surgeon. When the senior surgeon in the room (a female), introduced herself, he actually stated "Oh I didn't know women could be trauma surgeons." In an article published in the American Journal of Surgery in 2019, half of all hospitals with emergency general surgery services reported no female surgeons. For the subset of hospitals with EGS services who have an ACS Model, they reported a higher median proportion of women surgeons (17%).(3) Specifically in trauma surgery, women are still under-represented. 28% of surgeons who are board-certified in critical care are female. Thankfully, our voice is gaining strength. More women are going into surgical disciplines, and there are more woman in leadership positions in surgical organizations.(4) 29% of EAST members and 13% of AAST members are female, although there has been an increase in female executive leaders in AAST.(5) "Why should women have to sound like men to get people to listen to them? Why isn't it that everyone in the room should be quiet when she asks for quiet because she is a doctor asking for quiet?" "The theme was clear. Women physicians do not get the same respect men get when dealing with emergencies."(6) Women bring unique strengths to this discipline. It's not a matter of competing to prove that we are superior, but women are inherently different from men and this should be nurtured, not belittled, or ridiculed. Improved communication and patient engagement are just a few of the benefits we can bring to the team. Researchers Find Women Make Better Surgeons Than Men . "The authors attribute the favorable patient outcomes to the female doctors’ ability to communicate and engage with their patients to ensure compliance with medications and therapy, their adeptness at collaborating with colleagues and their tendency to adhere to guidelines when treating patients." This is not a simple problem, and it won't have a simple solution. So what can you do to combat the stereotypes and respectfully establish and maintain your position comparable to your male surgical colleagues? I've learned a few things over the years, with a handful of specific things over the years of my fellowship. Introduce yourself with your Title and name. Previously, I introduced myself as "Christina, part of the surgical team". I regarded my introduction as a display of humility. But I was actually unintentionally undermining my role in the team. I now introduce myself as "Dr ----, one of the trauma surgeons/ acute care surgeons" or "Dr ----, the trauma surgeon/ acute care surgeon who will be taking care of you." Find your team. Seek out mentors, or be a mentor for a younger trainee. Seek support from those who have led the way in this specialty. Get involved. This can be done at all levels, from hospital-level leadership and committee membership, city/ state/ national trauma organizations/ associations Counteract the negative thoughts that can accompany Imposter Syndrome. Keep a list of your strengths and the reason why you chose this specialty. 1. Stamp N. I'm a female surgeon. I feel uncomfortable telling girls they can be one, too. Washington Post. 29 July 2019. 2. McGuire K. Imposter Syndrome: The Dirty Little Secret of Successful Women (And Men Too). Association of Women Surgeons. 3 April 2019. 3. Oslock WM, Paredes AZ, Baselice HE, et al. Women surgeons and the emergence of acute care surgery programs. Am J Surg. 2019;218(4):803-808. 4. Haskins J. Where are all the women in surgery? Association of American Medical Colleges. 15 July 2019. 5. Foster SM, Knight J, Velopulos CG, et al. Gender distribution and leadership trends in trauma surgery societies. Trauma Surg Acute Care Open. 2020;5(1):1-5. 6. Riley, Edward. Voices in the OR: A Self-Reflection and Examination of Unconscious Bias. Doximity. 28 Oct 2020. Previous Next

< Back Delirium...what's going on? A 29-year-old male with moderate traumatic brain injury (TBI) remains intubated in the surgical ICU (SICU) due to agitation/ delirium during daily spontaneous awakening and breathing trials (SAT/ SBT). What are the clinical priorities? Rule out acute processes that can cause agitation and delirium, such as anemia, acidosis, hypoxemia, infection, intra-cranial process, fever, and an adverse drug reaction. Other potential causes? Immobility, "lines and tubes." Isolation, disorientation, lack of normal sleep-wake patterns Endocrine or metabolic derangements Organ dysfunction (renal disease, liver disease, etc) Withdrawal from chronic home medications (benzodiazepines, alcohol, psychiatric medication, etc.). What are the treatment principles for agitation and delirium? Treat organic reversible causes (treat infection, minimize unnecessary medication, etc.) Implement non-pharmacology therapy (sleep-wake cycles, lights and stimulation during the day and darkness at night) Pharmacologic agents can be used once reversible causes are remedied and non-pharmacologic therapy has been instituted. After the optimization of non-pharmacologic therapy, the patient was successfully extubated. A few days later on rounds, the patient was sitting up in bed. During our conversation, I noticed that he was drinking a Mountain Dew. His mom told us that he drinks multiple Mountain Dews every day (read- 6 or more). I told her that I suspect this had a significant role in his altered mental status during attempts at ventilator liberation. Management of Agitation and Delirium Definition Agitation is a psychomotor disturbance characterized by excessive motor activity and a feeling of “inner tension”. Delirium is an altered consciousness with reduced focus/ cognitive function. It is abrupt in onset and can have a fluctuating presentation. High prevelance, often misdiagnosed. Classified as hypoactive (most common, worse prognosis, difficult to diagnose), hyperactive (better prognosis) or mixed. Etiologies Acute illness- sepsis , electrolyte/ metabolism disorders, hyperthermia, hypoxia, hypotension, EtOH withdrawal, organ dysfunction, polytrauma, emergency surgery Patient factors- elderly, history of depression/ stroke/ dementia, history of EtOH abuse, tobacco use. Hearing or vision impairment. Iatrogenic- noise, discomfort, pain, sedative/ analgesics, ventilator dyssynchrony. Exacerbated by pain, anxiety, discomfort. Diagnosis [see charts below] Assess consciousness with Richmond Agitation-Sedation Scale (RASS). 10 point scale, ranging from combative to unarousable. Assess for delirium with Confusion Assessment Method for the ICU (CAM-ICU). 1-2 min test, 98% accurate in diagnosing delirium. Assess over 24 hrs to capture nocturnal symptoms. Non-Pharmacologic Treatment of Delirium Diagnose and manage underlying acute illness - Treat sepsis as appropriate- antibiotics, source control, etc. - Correct hypoxia, metabolic disturbances, dehydration, hyperthermia Non-pharmacologic interventions for anxiety/ discomfort[1] Periodic reorientation and reassurance from nursing staff Cognitive stimulation Correction of sensory deficits Management of environment (reassess need for invasive devices) Normalize sleep/wake cycles Minimize iatrogenic factors (sedation) Pharmacologic Therapy for Delirium Typical anti-psychotic- Haloperidol. MIND and HOPE-ICU trial- no difference in duration of delirium.[2,3] AID-ICU trial- no difference in mortality.[4] Atypical anti-psychotic- Quetiapine, Ziprasidone MIND-USA trial- no difference in delirium duration with either agent [5] Dexmedetomidine MENDS and SEDCOM trials- ↓ mechanical ventilation and ↓ delirium vs benzos [6,7] MIDEX and Prodex trial- non-inferior compared to benzos/ Propofol [8] DahLIA trial- quicker and more sustained resolution of delirium vs placebo [9] SPICE III Trial- similar mortality and similar number of delirium-free days [10] MENDS II Trial- similar number of delirium-free days vs Propofol.[11] Melatonin Pro-MEDIC Trial- prophylactic melatonin didn't decrease delirium prevalence[12] Assessment for Caffeine Withdrawal Obtaining a detailed patient history, or even a focused history of the most pertinent diagnoses or medication (blood thinners, cardiac disease) is often challenging in traumatically injured parents who may have decreased mental status due to injury or intoxication. Documenting daily caffeine intake is not typically a key component in a surgical history. However, caffeine is readily available and is the most commonly used drug in the world.[13] Unfortunately, it has significant systemic effects. Along with nicotine, it is gaining more attention as a potential etiology of altered mental status or other symptoms that would typically prompt extensive work-up. If a patient has persistent altered mental status after evaluating typical causes, consider the possibility that the patient could be missing their usual caffeine fix. "Withdrawal symptoms caused by people abruptly stopping smoking or drinking tea and coffee can include nausea, vomiting, headaches, and delirium and can last for up to two weeks."[14] References Faustino TN et al. Effectiveness of combined non-pharmacological interventions in the prevention of delirium in critically ill patients: A randomized clinical trial. J Crit Care. 2022;68:114-120. MIND Trial. Girard TD et al. Feasibility, efficacy, and safety of antipsychotics for intensive care unit delirium: The MIND randomized, placebo-controlled trial. Crit Care Med. 2010;38(2):428-437. HOPE-ICU Trial. Page VJ et al. Effect of intravenous haloperidol on the duration of delirium and coma in critically ill patients (Hope-ICU): a randomised, double-blind, placebo-controlled trial. Lancet Resp Med. 2013;1(7):515-523. AID-ICU Trial. Andersen-Ranberg NC et al. Haloperidol for the Treatment of Delirium in ICU Patients. N Engl J Med. Published online October 26, 2022. MIND-USA Trial. Girard TD et al. Haloperidol and Ziprasidone for Treatment of Delirium in Critical Illness. N Engl J Med. 2018;379(26):2506-2516. MENDS Trial. Hughes CG et al. Dexmedetomidine or Propofol for Sedation in Mechanically Ventilated Adults with Sepsis. N Engl J Med. 2021;384(15):1424-1436. SEDCOM Trial. Riker RR et al. Dexmedetomidine vs Midazolam for Sedation of Critically Ill Patients: A Randomized Trial. JAMA. 2009;301(5):489. MIDEX and PRODEX Trials. Jakob SM et al. Dexmedetomidine vs Midazolam or Propofol for Sedation During Prolonged Mechanical Ventilation: Two Randomized Controlled Trials. JAMA. 2012;307(11):1151. DahLIA Trial. Reade MC et al. Effect of Dexmedetomidine Added to Standard Care on Ventilator-Free Time in Patients With Agitated Delirium: A Randomized Clinical Trial. JAMA. 2016;315(14):1460. SPICE III Trial. Shehabi Y et al. Early Sedation with Dexmedetomidine in Critically Ill Patients. N Engl J Med. 2019;380(26):2506-2517. MENDS II Trial. Hughes CG et al. Dexmedetomidine or Propofol for Sedation in Mechanically Ventilated Adults with Sepsis. N Engl J Med. 2021;384(15):1424-1436. Pro-MEDIC Trial. Wibrow B et al. Prophylactic melatonin for delirium in intensive care (Pro-MEDIC): a randomized controlled trial. Intensive Care Med. 2022;48(4):414-425. Caffeine: The chemistry behind the world’s most popular drug Stephenson J. Nicotine and caffeine withdrawal may affect ICU patients. Nursing Times. June 2019 . RASS for Agitation Assessment CAM-ICU For Delirium Assessment Previous Next

< Back Dogs #1 Supplies This is not professional/ medical advice. These are all based on my personal experience. I’m not a paid sponsor for any of these items. I have included reviews where appropriate. Treats and Edible Chew Items Bully Sticks- WOOF Bully Sticks Dog Treats, Made with Grass-Fed Beef Amazon Link Training treats- Pupford Freeze-Dried Training Treats Amazon Link Training treats- Pupford Soft and Chewy Training Treats Amazon Link Bison- Tilted Barn, Miniwags, Bison Recipe Chewy Link Chicken, Jones Natural Chews- Tender Taffy Soft Chicken Blend Jones Link Salmon and Sweet Potato- Trader Joe’s Ebay Link (picture—go in person!) Chicken- Trader Joe’s Jerky Sticks, Chicken Recipes Ebay Link (picture—go in person!) Pupsicles- WOOF Pupsicle Refill Pops Amazon Link Pupsicle Silicone Mold Amazon Link Lick Mats Amazon Link Notes: Pupsicles are advertised to last 20-40 minutes…my pup finishes them in about 5 minutes. So they aren’t a very cost-effective treat for her. But if your pup is a less aggressive licker, these refills, as well as a mold so you can prepare your own homemade pops, might be perfect for you! Lick mats have become very handy for grooming- I load them with wet dog food, freeze them and they last for a long grooming session. “Safe” Chew Items - made of edible material, although not specifically intended for consumption Sticks- Pupstages Dogwood Dog Chew Toy (Size Large) Amazon Link Sticks- Pupstages Dog Chew Toy (Natural and Hemp Flavors) (Medium) Amazon Link Nylon Chew Toys- Benebone Dog Chew Toy- puppy phase Amazon Link Ropes- Hemp Rope Dog Toys Amazon Link Meal Time Dry kibble, puppy food, Purina Pro Plan Chicken and Rice Amazon Link Dry kibble, adult food, Purina Pro Plan Chicken and Rice Amazon Link Wet food, puppy, Purina Pro Plan Chicken and Rice Amazon Link Wet food, adult, Purina Pro Plan Chicken and Rice Amazon Link Snuffle mat Amazon Link Slow feeder, West Paw Toppl toy Amazon Link Slow feeder, puzzle ball Amazon Link Dog food containers Amazon Link Notes: My pup uses her snuffle mat for almost every meal, occasionally uses the puzzle ball or other puzzles like toilet paper rolls. Similar to the lick mats, the West Paw Toppl toy can be filled with wet food and frozen. This will provide a long licking session. Crate Crate- MidWest Homes for Dogs Amazon Link Exercise pen (ex-pen)- MidWest Homes for Dogs Amazon Link Pet Camera, Remote Controlled Security Camera Amazon Link Notes: I used the exercise pen for the first few nights my pup was home with me, but she quickly learned how to climb over it (don’t ask…I have no clue). But then I used the panels fully extended to prevent her from accessing things in the house, such as the bookcase and TV stand, as she learned boundaries. Puppy Problem Solving Pet Odor Eliminator- Angry Orange Concentrate Amazon Link Vinegar and water (50/50 mix) in a squirt bottle Notes: Vinegar and water is a great natural option for cleaning puppy pee accidents on solid surfaces. I used Angry Orange for accidents on absorbable surfaces, like the rug or car seat. Training Treat pouch, Mighty Paw Amazon Link Treat pouch, Lanney Amazon Link Clicker Amazon Link Belt with bells for potty training Amazon Link Scent Training, Race&Herd Original Dog Scent Training Kit Amazon Link Notes: Both treat pouches have a main pouch and a front pouch (net pouch and zipper pocket), can either be worn over the shoulder/ across the chest or clipped around the waist like a fanny pack. Both have poop bag pouches. The Mighty Paw pouch has a magnetic opening, while the pouch has a drawstring opening. Travel Dog sling carrier Amazon Link Car seat Amazon Link Water bowl, collapsible, with carbiner for easy carrying Amazon Link Notes: I used the dog sling carrier during puppy socialization before my pup was fully vaccinated. Bath and grooming Hand-held shower head with 6 ft. hose Amazon Link Shampoo- Wahl USA Gentle Puppy Shampoo Amazon Link Detangling Spray- BioSilk for Dogs Amazon Link Slicker Brush- Coastal Dog Slicker Brush Amazon Link Grooming scissors and comb set Amazon Link Clippers- Andis, 2-speed, Corded Electric (with size 10 blade) Amazon Link Additional clipper blade, size 7 Amazon Link Additional clipper blade, size 3 ¾ Amazon Link Clipper comb guards Amazon Link Grooming Table- Yaheetech 46'' Pet Grooming Table, Weight Up to 265Lb Amazon Link Other Hygiene Toothpaste and toothbrush- Vet’s Best (peanut butter flavor) Amazon Link Nail clippers Amazon Link Styptic Powder- DOGSWELL Remedy Recovery Amazon Link Dog cleaning wipes (Arm and Hammer wet wipes) Amazon Link Eye wipes- Earth Rated Vet-Developed Dog Eye Wipes Amazon Link Eye comb (for eye boogers) Amazon Link Ear powder (for plucking ear hair)- Miracle Care Ear Powder Amazon Link Paw cleaning brush- shampoo with built-in silicone brush Amazon Link Paw cleaning cup with internal silicone bristles Amazon Link Notes: I do NOT endorse ear plucking. This is a discussion you should have with your veterinarian. However, if you do pluck, this stuff works really well. Apparel and Winter Gear Fleece Jacket, Gold Paw Series GoldPaw Link Winter Jacket, Plaid Amazon Link Winter Jacket, RuffWear Powder Hound Dog Jacket RuffWear Link Winter boots- Youly, The Adventurer, All-Weather boots PetCo Link Summer boots Amazon Link Paw Wax- Musher's Secret Amazon Link Post-spay body suit, BellyGuard surgery recovery suit Amazon Link Notes: Winter boots were an in-person purchase at PetCo, when we had a surprise snow storm and Amazon delivery wasn’t available. They fit really well, although the velcro isn’t very hearty- I’ve had to repair them by hand. Leashes, Collars and Tethers Collar, neoprene and nylon Amazon Link Collar, nylon, waterproof (doesn’t bleed color onto fur) Amazon Link Identification tag, silent, slide on collar Amazon Link Medium-length nylon leash, 15 ft- Hi Kiss Dog/Puppy Obedience Amazon Link Chew-Proof Tether, 6 foot Amazon Link Chew-Proof Tether, 50 foot Amazon Link Back-clip harness for car rides Amazon Link Notes: Bovie loves chewing leashes, and we went through several nylon leashes before I wised up and purchased chew-proof varieties, specifically for tethering in the house. For example, when she was a puppy, we trained her to stay on her place during mealtime, and she was tethered as a reminder. When we are outside eating or working, she has a 50 foot tether so she doesn’t take off down the hill or into a neighbors yard. I don’t keep her tethered for extended periods of time and she’s never unattended while tethered. Previous Next

And You Really Should be Nice to People It's a Small World < Back And You Really Should be Nice to People The medical community is incredibly small and interconnected. This can be very beneficial, but can also create challenges if interpersonal discord arises. Word travels fast and it's easy to burn bridges. In the medical field, there is a palpable tension between certain specialties. Not every hospital has the same procedure for managing trauma. However, in the countless hospitals I've worked in, clinicians in Emergency Medicine and Trauma Surgery work hand in hand to manage severely injured trauma patients. We have different training experiences and different management styles. When we (Trauma Surgery) come down to the trauma bay to evaluate a patient, we are a visitor. Yes, in a busy hospital, we might be incredibly frequent visitors. But still, we are guests in another department's home. Despite the best intentions, and perhaps even because of varying perspectives on what is "the best" intention, it is not a surprise that the trauma bay can serve as a breeding ground for animosity,(1) unless there are deliberate efforts to prevent conflict. Thankfully, creating a common language and developing standard practices is possible through mutually developed protocols, as well as principles in ATLS. This is crucial to effective patient care. I am grateful that I completed my Acute Care Surgery fellowship at a hospital system with a phenomenal relationship with our Emergency Department colleagues. I won't exaggerate and deny any conflicts, but there was a culture of mutual respect and a common goal of optimal patient care that I had never experienced before. Why Does It Matter? I started this post to share a story of why it's important to be nice to everyone you encounter. I mean, besides the fact that I believe that we should be kind and compassionate to everyone. At one facility that I worked, there was a less than friendly relationship between surgery and the emergency department. Again, I will confess that I likely had several of my own negative interactions. However, my general principle is based on what I described above. I consider my behavior and attitude to be at least a basic level of respect and decency to the providers that I interacted with. In contrast to unpleasant providers, I appeared to be above average. About 5 years ago, I was preparing for a deployment. I had the misfortune of being attacked by several dogs and required a series of rabies vaccines, which delayed my medical clearance. Thankfully, one of the ER providers from my hospital was at pre-deployment with me. He called a senior medical officer and obtained clearance so I could proceed without delay. It would have been easy for me to dismiss this provider during any of our countless interactions. If I had been consistently less pleasant, I suspect that he would have maintained a basic level of decency despite my poor behavior. But it's unlikely that he would have extended himself to advocate on my behalf. You never know what interaction could make the difference, so we should be nice to everyone. 1. Why Can't Emergency Medicine and Surgery Just Get Along? EmCrit Podcast. Previous Next

< Back Shakshuka- A North African Dish Ingredients 1 large red bell pepper, thinly sliced 1 large yellow bell pepper, sliced 1 red onion, sliced 3-4 garlic cloves, diced ¾ tsp salt cracked pepper to taste 1 tsp cumin 1 tsp sugar ½ tsp smoked paprika ½ tsp chili flakes 3 medium tomatoes diced small ⅓ c white wine or water 1 T fresh basil ribbons or chopped Italian parsley 4 -6 Extra large organic eggs Other optional additions: crumbled feta or goat cheese 1 C browned chorizo ¼ C finely diced spanish style cured Chorizo or Merguez, a North African spiced sausage Instructions 1. Preheat oven to 400F. 2. In a large cast iron skillet, heat the olive oil over medium heat. Add the onion and cook until tender, about 5 minutes. If adding raw chorizo, brown it with the onions. 3. Add the sliced peppers and garlic, and turn heat down to med-low and cook for 5 more minutes, until peppers are tender. If adding the cured spanish chorizo or Merguez sausage, add it now. Add all spices, sugar and salt. Cook for 2 more minutes. Add fresh tomatoes and white wine. 4. Simmer on low for 15 minutes, adding more water if it gets too dry or thick- you want a stew-like consistency. After tomatoes cook down, taste, it should be full flavored- adjust salt and sugar if necessary. Crack 4-6 eggs over the mixture, sprinkling each egg with salt and cracked pepper. Add crumble goat cheese or feta over the top and place in the 400F oven. 5. Bake until egg whites are cooked (about 7 minutes) and yolks are still soft. Remove from oven and top with fresh basil (or Italian parsley). Serve with toast or crusty bread. Veggies sizzling Previous Ready for the oven Yummy! Next

< Back Pneumonia...pending Pneumonia Previous Next

< Back Gallbladder Disease Cholecystectomy (gallbladder removal) is one of the most common operative procedures performed. What does the gallbladder do? Your gallbladder stores bile and enzymes from the liver. When you eat, your gallbladder squeezes to drain bile into the intestines to help you digest food. What are the reasons for cholecystectomy? Symptomatic cholelithiasis. If gallstones are present, they can lead to increased pressure and pain when the gallbladder contracts. Typically occurs with a fatty meal. Pain can last minutes to hours. Acute cholecystitis. When the gallbladder drainage is blocked by gallstones, it can become acutely inflamed. Symptoms are similar to symptomatic cholelithiasis, but the symptoms don't resolve. Source: UpToDate Images: Anatomy of the Gallbladder What does surgery entail? What are the risks of the procedure? Your gallbladder is under your liver. Laparoscopic surgery is typically done with an incision at your belly button and 3 incisions under your ribs on the right upper abdomen. There is a risk of pain, bleeding, and infection with any surgical procedure. Specific to this procedure, there is a risk of damage to surrounding organs, including the liver and intestines. The worst-case scenario is damage to the tube that drains from the liver into the small intestine, called the common bile duct. This complication is infrequent, but if it occurs, you will need more procedures and a longer hospital stay. If we can't see things safely laparoscopically, we will proceed with an open incision under your ribs on the right. This is not common with elective surgery and is more likely in elderly diabetic patients with acute severe inflammation. *IOC- there is an additional procedure that we will perform that shows us the bile ducts and allows us to see if there are any stones in the bile duct that can cause obstruction. What can I expect post-operatively? You will have several small incisions from the laparoscopic port sites. They will have absorbable sutures, nothing that needs to be removed. You will have glue or gauze and paper tape on the incisions. The glue will peel off on its own in 10-14 days. If you have gauze, you can remove this in two days and shower like normal. You will have paper tape strips on the incision, and these will peel off on their own. You are at risk for a hernia through the small incisions, so avoid heavy lifting for 4 weeks after surgery. You may take acetaminophen (Tylenol) and ibuprofen (Motrin) as needed for pain. These can be taken at the same time. Take the narcotic pain medication if your pain is severe despite the acetaminophen and ibuprofen. After the few first days, you should work on decreasing the number of narcotics that you are taking. What can I eat after surgery? There are no specific dietary restrictions. However, if you eat a fatty meal, it may cause loose stool (diarrhea) until your body adjusts to not having your gallbladder, which previously stored the chemicals used to digest fatty food. This is seen in about 10% of patients and usually resolves. If it lasts more than a few weeks, there are medication options to treat this. What should I be worried about after surgery? If you have fever >101 F, severe nausea/ vomiting, inability to tolerate liquids, severe abdominal pain, increasing redness, or drainage from your incisions. UpToDate Patient Education Patient education: Gallstones (Beyond the Basics) Patient Information from Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Gallbladder Removal Surgery (Cholecystectomy) American College of Surgeons Operation Brochures Cholecystectomy: Surgical Removal of the Gallbladder Previous Next

< Back Thoracoabdominal Wound A 32-year-old male is brought to the ER after sustaining a gunshot wound to the right thoraco-abdomen. He is hemodynamically stable. What are the initial steps of evaluation and management? Imaging? Secondary survey to rule out other wounds. FAST exam. CXR. What injuries must be considered with these wounds and imaging patterns? Chest (heart, lungs, etc.), abdomen (solid organs or hollow viscus), and diaphragm. He underwent exploratory laparotomy. He was found to have a right diaphragm defect, which was repaired primarily. There was a transhepatic GSW and hepatorrhaphy was performed with chromic suture. A blast injury to the anterior gastro-esophageal junction was buttressed with an anterior Dor fundoplication. Management of Thoracoabdominal Wounds The thoraco-abdomen is between the nipples and the costal margin. Organs in the chest and abdomen can be injured, and the diaphragm is also at risk. Liver Trauma Management depends on how it is diagnosed and the patient's hemodynamic stability and physical exam. Diagnosed pre-operatively on CT scan + no concern for the need for operative intervention for concurrent injury→ non-operative management if the patient is hemodynamically stable without peritonitis. Embolization should be considered in adults with active arterial extravasation on CT. Operative intervention is indicated for hemodynamic instability, ongoing transfusion requirement, and/ or change in the abdominal exam. Diagnosed intra-operatively→ management depends on the severity and presence of bleeding, presence of concomitant injuries. Hemorrhage control is the immediate concern. Manual pressure and packing (sandwich lap pads above and below) first. If this is ineffective, use the Pringle maneuver (hepatic inflow control)→ if bleeding stops, it was either hepatic artery or portal venous in origin. If bleeding continues, hepatic vein or IVC are likely injured. Minimal bleeding can be controlled with cautery, hemostatic agents, omental packing, or argon beam coagulation. Moderate bleeding from a laceration from often be controlled with suture hepatorrhaphy. More significant bleeding may require non-anatomic resection or vessel ligation. Topical hemostatic agents Absorbable hemostatics Oxidized regenerated cellulose- Surgicel, Surgicel Fibrillar (sheet), Surgicel NuKnit Polysaccharide- Arista Porcine collagen (gelatin matrix)- sponge, film, or powder. Brands- Gelfoam, Gelfilm, Surgifoam. Bovine collagen (microfibrillar)- sponge, sheet, powder. Brands- Avitene, Ultrafoam. Sealants with thrombin or fibrin Thrombin, reconstituted (Recothrom) Thrombin + collagen + chondroitin sulfate (Hemoblast) Thrombin + bovine gelatin (Floseal) Thrombin + porcine gelatin (Surgiflo) Thrombin + fibrinogen + aprotinin + plasminogen (Tisseel) Thrombin + fibrinogen + albumin (Evicel) QuikClot- kaolin HemCon- chitosan If there is a trans-hepatic wound, tamponade can be created by threading a red rubber catheter through a Penrose drain, placing this into the wound, and then filling the Penrose with saline. Stabina S, Kaminskis A, Pupelis G. Start of Polytrauma Management in University Hospital: First Experience with Liver Trauma. Acta Chirurgica Latviensis. 2014;14(1):20-25. Previous Next

< Back Vent Mgmt #3: Pressures Inspiratory Pressures Pressure Controlled Ventilation (PCV) End-inspiratory pressure= alveolar pressure. The pressure is essentially constant during PCV- high flow at the beginning to get to target pressure, then flow tapers until it ends (no airflow at end inspiration). Can't measure resistance because flow rate is dynamic. Volume Controlled Ventilation (VCV) Peak inspiratory pressure (PIP)- maximal pressure with inspiration. Sum of plateau pressure and pressure required to overcome airway resistance. Keep <40 cm H2O, SCCM recommends below 30 for ARDS. Abnormalities: elevated PIP indicates high resistance (secretions, bronchospasm, biting tube). Plateau pressure= alveolar pressure. Mean pressure during end-inspiratory pause, basically when there is no air movement. Not affected by resistance. Goal ≤30 cm H2O. Abnormalities: elevated plateau pressure indicates poor compliance. Driving pressure= plateau - PEEP. Goal ≤15 cm H2O (>15 is associated with ↑mortality). PEEP can either improve or worsen driving pressure. If the set PEEP promotes recruitment→ ↓driving pressure. If the set PEEP creates overdistension of the alveoli→ ↑driving pressure. End Expiratory Pressure Positive end expiratory pressure (PEEP)- lowest pressure that avoids alveolar collapse, which occurs when intrapleural pressure is higher than intra-alveolar pressure. This is indicated by the lower bend on the pressure/ volume curve, known as the lower inflection point. Mean Airway Pressure Mean airway pressure (MAP)- average pressure the lungs are exposed to during the breathing cycle. One of the two parameters that determine oxygenation. - How to increase MAP: ↑PEEP. If using IRV, ↑inspiratory time (Thigh) and ↑inspiratory pressure (Phigh). Parameters that Impact Airway Pressures Resistance- change in pressure relative to flow (PIP - plateau/ peak inspiratory flow). Relationship between PIP and plateau is directly related to airway resistance. ↑PIP and [PIP - plateau >5 cmH2O]= ↑resistance (bronchospasm, ETT obstruction/ kink). ↑PIP and ↑plateau [PIP - plateau <5 cmH2O]= ↓compliance (PTX, ARDS, pneumonia, edema, auto-PEEP). Compliance- change in volume per change in pressure. Normal- 50-100 mL/ cm H2O Previous Next