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5 Team of Teams New Rules of Engagement for a Complex World - From retired General Stanley McChrystal. Guidance on developing an adaptable, agile, and unified organization. - Changes in the nature of war necessarily lead to changes in leadership and team dynamics. - Given the dynamic nature of current combat, the prevalence of unknown unknowns, and the rapid pace of information dispersion, it is unreasonable for every leadership level to approve every maneuver. - Teams need to be competent and well-trained. But in this current environment, it would be prohibitively cumbersome to require the commander's involvement in every decision while remaining agile and quickly responding to constant changes. In contrast, developing a strong team and providing a common goal, an overarching mission, allows teams to execute, react, and adjust to shifting battlefields. The end state serves as a guide, and the group draws from their training to accomplish the mission. Previous Next

10 < Back Research Resources Literature Search PubMed . National Library of Medicine, database to search for biomedical and life sciences literature. Cochrane Library . Leading journal and database for systematic reviews in health care. For a more extensive list of surgical and critical care references, please see Medical Literature . References Zotero . Free computer program that organizes all your medical literature. Highly recommend. You can create folders and add tags to help index your documents. If you want to sync your documents across devices (phone, tablet, etc), you can purchase a storage subscription. 2 GB costs $20/ year, 6 GB costs $60/ year and $120/ year gives you unlimited data storage. Tools and shortcuts in Zotero: Automatically add articles from any electronic resource (PubMed, journal website, etc). Easily tag and sort documents into categories to help easily locate articles on a particular topic. Search your entire database of documents for any author, title, year of publication, and journal source, and perhaps most usefully- search for any individual words to find a comprehensive list of documents that address a particular topic. There is a note panel on the right side of the document that allows you to type a note while reading the article. Automatically create a note from the text you highlight while reading an article. Alternatively, if you choose to type your own notes, you can also highlight text and add a single highlighted section to the note. EndNote . Free application that simplifies citation management. Use Cite While You Write to embed references while writing manuscripts. Data Analysis Covidence . Systematic review management program. It requires a subscription. GraphPad QuickCalcs . I do NOT endorse this as the most reliable/ valid/ precise options for doing statistics. HOWEVER, I have used it for simple calculations and it always matches or is incredibly close to what my formally trained statistician reported. PubMed . National Library of Medicine, database to search for biomedical and life sciences literature. Cochrane Library . Leading journal and database for systematic reviews in health care. Research Manuscript Submission Manuscript Title Page Template .docx Download DOCX • 49KB Manuscript Cover Letter Template .docx Download DOCX • 49KB Previous Next

4 Everything is Obvious ...Once You Know the Answer - Countless examples of how we understand cause and effect much less than we think. - "No matter where we live, our lives are guided and shaped by unwritten rules-so many of them, in fact, that we couldn't write them all down if we tried." - The relative number of people who are organ donors varies between countries. Why? Religion, education, fear about receiving less aggressive care if you are an organ donor, et cetera. The default option for registration can explain the difference between two neighboring European countries. One country requires the citizen to actively elect to be a donor, while another country requires a citizen to decline the default option for being a donor. - "We claim...that the Mona Lisa is the most famous painting in the world because it has attributes X, Y and Z. But really what we’re saying is that the Mona Lisa is famous because it’s more like the Mona Lisa than anything else." Previous Next

< Back Pneumothorax American Thoracic Society- Patient Education | INFORMATION SERIES What is a Spontaneous Pneumothorax? Tube Thoracostomy (Chest Tube) You have a pneumothorax. This happens when your lung collapses and there is air in your chest. This can be spontaneous but is also frequently secondary to trauma. Imagine your lung is a balloon. When there is a hole in the balloon (penetrating wound to the chest, rib fracture, etc), the balloon collapses. When you breath in, the air moves from your airway, into the balloon and then out into your chest, the space around your lung. A chest tube is placed to evacuate the air from your chest and allow your lung (the balloon) to reexpand. As long as the hole in the lung is small, removing the air is generally all that is required. This is because when the lung is stuck back up to the inside of your chest, air stops leaking into the space around your lung. Surgery is infrequently required for management of a pneumothorax. This occurs when the lung fails to reinflate despite placement of a chest tube. It can also be required if there is an “air leak”. An air leak is the result of the ongoing leakage of air from the lung into the chest. The air that moves into the chest continues to be evacuated into the chest tube, and this is seen as bubbles in one window of the chest tube drainage canister. Spontaneous pneumothorax is often due to apical blebs, which are small areas at the lung of your lung that have thinned out and can rupture, with a similar results as a traumatic hole in the balloon that is the lung. Previous Next

Disclaimers for Vignettes Disclaimers This website is provided for educational and informational purposes only and although every effort has been made to present accurate information, this is not a substitute for professional advice. Always seek guidance from a qualified healthcare provider or physician for inquiries regarding medical conditions, treatments, or before embarking on any new healthcare regimen. Never disregard professional medical advice or delay in seeking it due to information found here. If you think you may have a medical emergency, call 911 or go to the nearest emergency room immediately. No physician-patient relationship is created by use of this website. The practice of medicine relies on using the best available evidence, but clinical scenarios often lack clear-cut answers. Every clinical situation is unique, and no single solution applies universally. Clinical guidelines attempt to provide recommendations that apply in most situations, but that are not one-size-fits-all solutions and they do not replace clinical judgment. The infinite variety of patient, disease, and environmental factors influencing clinical decision-making cannot be fully accounted for in medical literature. Therefore, any variance in the approach of physicians from what is presented here does not necessarily signify an error on their part. Some of the images on this website contain graphic content that may be disturbing or distressing to some audiences. Viewer discretion is advised. HIPPA- vignettes are presented to provide clinical education, with considerable care to prevent any patient from being identified. Protected health information and patient identifiers (name/ location/ date/ occupation/ contact information/ identifiable photos/ numerics such as SSN/MRN/insurance) have been withheld. Unique details have been removed from text and images. Details that don't impact the clinical case, such as age and gender, have been modified to obscure each patient's identity. Many stories are heavily modified to highlight the key learning points and some scenarios are complete fabrications. The scenarios span my entire 17 years of experience in the medical field, and they are seen on a routine basis in our field. I have not shared one-of-a-kind or sensational cases because the risk of disclosing identifiable details heavily outweighs any potential educational benefit. The views, opinions, and assertions expressed herein are those of the author and do not reflect the official policy or position of the Department of Defense. These scenarios are not designed to portray the comprehensive evaluation and management of acute care surgery patients. Many common steps are omitted, as the intent is to highlight unique learning points for different clinical scenarios. Trauma scenarios DO NOT teach all the basic principles of ATLS, so there is a minimal repetition of basic principles (primary and secondary survey). Any of the products found on this website are not specific endorsements. I do not receive any monetary compensation or non-monetary incentives for the sale of any items seen here.

< Back Frequently Asked Questions What level of schooling/ education/ training is required to be an Acute Care Surgeon? - Traditionally, 4 years of undergraduate education and 4 years of medical school. - Surgery residency, typically 5 clinical years, sometimes an optional or mandatory research year (or more). - Following residency, there is a written exam that qualifies you to take the oral boards. Passing oral boards equates to Board Certification in General Surgery. - Fellowship- one year mandatory for surgical critical care certification. Acute Care Surgery requires two years of training. - Following a surgical critical care fellowship (after completing one year SCC fellowship, or after the critical care year of your ACS fellowship), there is a written exam requirement for Board Certification in Surgical Critical Care. What is the best part of your job? Relieving patients suffering. We meet people on what is probably the worst day of their life. Whether it’s a traumatic injury or a surgical emergency, our patients arrive in crisis. We can minimize or alleviate their suffering. What is the worst part of your job? Having to tell families that their loved one died. We meet people on what is probably the worst day of their life. We have to quickly establish rapport and tell them terrible news. We ask strangers to trust that we did everything to keep their child, spouse, or parent alive. Previous Next

< Back Anemia...pending Anemia Previous Next

9 < Back Annual Conferences American Association for the Surgey of Trauma (AAST) Annual Meeting Past and Future Meetings 2024: September 11-14, Paris Hotel, Las Vegas, NV 2025: September 10-13, Marriott Boston Copley Place, Boston, MA Meet senior trauma surgeons and hear about cutting edge research in the field of trauma, critical care and emergency general surgery. Eastern Association for the Surgery of Trauma (EAST) Annual Scientific Assembly Next Meeting 2025: January 14-18, JW Marriott Tucson Starr Pass Resort & Spa , Tuscon, AZ Meet senior trauma surgeons and hear about cutting edge research in the field of trauma, critical care and emergency general surgery. Mattox Vegas TCCACS- Trauma, Critical Care & Acute Care Surgery Next Meeting 2024: April 15-17, Caesars Palace, Las Vegas, NV If you are looking for high-yield educational content and you can only go to one conference a year, this is the one. Best analogy: this conference is like drinking from a fire hose. American College of Surgeons (ACS) Clinical Congress Next Meeting 2024: October 19-22, San Francisco, CA Previous Next

< Back Just Cellulitis...or something worse.... A 42-year-old female presents to the ED with one week of painful swelling of her left medial upper thigh. Her past medical history is remarkable for diabetes, morbid obesity, and rheumatoid arthritis, for which she takes immunomodulator therapy. She had been seen by a PCM earlier in the week and was started on antibiotics. She returned to her PCM when she continued to have pain and swelling and she was then sent to the ER for evaluation. She was concerned because the redness was extending to her groin and lower abdomen. On exam, she had redness and edema to her left lower abdominal wall extending midway down her thigh. Initial x-ray image What are the signs and symptoms suggestive of NSTI? Symptoms- fevers, painful skin lesion (redness, swelling, warmth) Signs- tachycardia, potentially hypotension. Skin warmth, edema, foul-smelling drainage, blistered or sloughing skin, crepitus. *Pain out of proportion to exam is a concerning finding. What workup should be performed? Labs- CBC, electrolytes, lactate Imaging- x-ray, ultrasound to rule out abscess, CT An ultrasound was performed, but it was non-diagnostic. There was no obvious underlying abscess. Why is ultrasound difficult with NSTI present? Soft tissue air obscures the ultrasound images. Evidence of artifact on the ultrasound can be suggestive of NSTI. What is the initial treatment of NSTI? Like any septic patient, antibiotics, resuscitation, and rapid source control are paramount. For necrotizing soft tissue infections, source control requires expeditious surgical exploration and debridement. Representative image from CT scan- upper thigh Representative image from CT scan- lower abdominal wall After starting broad-spectrum antibiotics and fluid resuscitation, the patient was taken to the operating room. Upon exploration, the tissue planes were easily dissected and there was copious grey-tinged malodorous fluid. The fluid was cultured to allow tailoring of antibiotic therapy. All necrotic tissue was excised and the wound was left open with gauze packing. She required low-dose norepinephrine during the case and had an elevated lactate. She remained intubated and was taken to the ICU. She returned each of the following 3 days until there was no more evidence of necrotic tissue or undrained infection. At that time a wound vac was placed and she returned for wound vac changes every 3 days. Management of Necrotizing Soft Tissue Infection (NSTI) Risk factors- diabetes, immunosuppression, malnutrition, obesity, IV drug use. Bacteriology- often polymicrobial (Type 1), 20% are monomicrobial (Group A strep or S aureus). Culture with Gram + rods= Clostridia (Type III). Diagnosis [1] Patients may present with sepsis and multi-system organ failure. Physical Exam- erythema or discolored skin, edema, pain out of proportion to exam, bullae, crepitus (late finding). Fever, hypotension. Imaging- CT is more reliable than plain films. MRI is most effective but may delay care. Plain films- gas in soft tissues MRI- fascial thickening CT- soft tissue air, muscle edema, fluid collections, thickened non-enhancing fascia Labs- leukocytosis, elevated lactate. Blood cultures. LRINEC score- ≥6 is suspicious, ≥8 is strongly predictive. Low sensitivity, not reliable to rule-out NSTI.[1,2] CRP ≥150= 4 points WBC 15-25= 1 point, >25= 2 points Hgb 11-13.5= 1 point, <11= 2 points Sodium <135= 2 points Cr >1.4= 2 points Glucose >180= 1 point Intraoperative findings: dishwater-like fluid is frequently encountered. Tissue planes easily separate, including the soft tissue separating from the underlying fascia. Management Rapid resuscitation, antibiotics, and surgical excision. If there is a high clinical suspicion, don't delay surgery to await imaging. Obtain tissue culture intraoperatively. Antibiotics Broad-spectrum until cultures available- vanco OR linezolid + pip/tazo OR carbapenem OR ceftriaxone/metronidazole S aureus- nafcillin, cefazolin, vancomycin, clindamycin Group A strep OR Clostridium- clindamycin and penicillin. Adjuvant Therapies IV immunoglobulin- neutralize Strep or clostridia toxin. Hyperbarics- no clear benefit. Immunomodulators? There are comprehensive reviews of the current practices regarding diagnosis and treatment of NSTI in Lancet and the New England Journal of Medicine.[3,4] References Fernando SM. Necrotizing Soft Tissue Infection: Diagnostic Accuracy of Physical Examination, Imaging, and LRINEC Score: A Systematic Review and Meta-Analysis. Ann Surg. 2019 Jan;269(1):58-65. Wong CH et al. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: A tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med. 2004;32 (7):1535-1541. Hua C et al. Necrotising soft-tissue infections. Lancet Infect Dis. 2023 Mar;23(3):e81-e94. Stevens DL et al. Necrotizing Soft-Tissue Infections. N Engl J Med. 2017;377(23):2253-2265. Previous Next

12 < Back Other Resources Radiology Radiopaedia.org . Open-edit radiology resource, compiled by radiologists and other health professionals from across the globe. How to Read a Chest X-Ray: The Graphic Novel and Drawing Book. Download this “Dummies Guide” to reading chest x-rays and brush up on the basics. Appropriateness Criteria. Evidence-based guidelines to assist providers in making the most appropriate imaging or treatment decision for a specific clinical condition. Acute Right Upper Quadrant Pain Acute Right Lower Quadrant Pain Previous Next

2 Range Why Generalists Triumph in a Specialized World - Early expertise and overspecialization do not equate to success. Having a breadth of knowledge is key to solving issues that cross different disciplines. - An extensive explanation of the benefit of the breadth of knowledge and the risks of super sub-specialization. Loss of cross-communication between silos of isolated components. - Wicked problems- issues that require outside-the-box thinking, can't be solved by relying on specialization but needs interaction between various contexts. - Capitalize on the varied backgrounds when trying to solve a problem. Gathering 10 specialists who all share the same knowledge and experience to focus on one issue can easily lead to a dead-end- without the benefit of new and fresh ideas, the team ends up in a loop. Diversity can exponentially increase problem-solving by drawing from different perspectives, viewpoints, and thought processes. - Contrasts to the 10,000-hour rule, which asserts the benefits of focused training and specialization. Previous Next

< Back Anorectal Disease Anorectal pain is an incredibly common condition . Thanks to our low-fiber Western diet and often inadequate hydration, constipation is a frequent occurrence. People also often spend long periods on the toilet. We used to read books, but now many play games or text on their smartphone. Constipation and prolonged sitting on the toilet can lead to several different problems. While discussing these symptoms can be awkard or uncomfortable, please talk to your doctor if your symptoms don't go away on their own. So what is anorectal pain? Although "butt pain" may be a common complaint, I want to be clear with my explanations. In reality, “butt” more accurately refers to the gluteal region, which is also known colloquially as derriere, buttock, backside, or fanny. It may be simplest to describe the butt as the area that rests on the surface of a chair when you sit. Anorectal refers to a more specific location, the anus and rectum, where stool passes through when you have a bowel movement. Please see the anatomically correct depiction below. What are the common causes of anorectal pain? Fissures Hemorrhoids Pruritis Ani Abscesses Less common- pelvic floor dysfunction, cancer Anatomy of the anus and rectum Two sphincter complexes encircle the rectal vault. The internal sphincter provides 85% of the resting tone. It is under involuntary control- this is how your body controls when you have a bowel movement. The external sphincter provides 15% of resting tone- it is under voluntary control, which means this is how you consciously control holding in a bowel movement. The internal hemorrhoids are veins that line the inside of the rectum, while the external hemorrhoid plexus is on the anal verge. These means that hemorrhoids are a NORMAL part of anatomy! They fill with blood to aid in incontinence, helping you control when you have a bowel movement. Anything that increases pressure in the abdomen, including prolonged straining, coughing, pregnancy, and enlarged prostate requiring straining to urinate, can lead to abnormally large venous plexuses, which are what most people know as hemorrhoids. See “Hemorrhoids” below for more details. Glands line the inside of the rectum and help lubricate stool. When the glands become obstructed, they can lead to abscesses. What are the common symptoms of anorectal disease? Pain Bleeding- either blood dripping in the toilet, blood on the toilet paper with wiping, and blood mixed with or on the stool's surface. Mucus drainage (constant moisture), which can cause challenges with perianal hygiene Pruritis (itching) Palpable mass Constipation/ diarrhea, incomplete voiding What causes anorectal disease? Prolonged straining or prolonged time sitting on the toilet, often due to constipation (hemorrhoids) Constipation and passing a hard stool can lead to tears in the skin (fissure) Underlying gastrointestinal disease (inflammatory bowel disease, etc.) How do I prevent anorectal disease? The goal is to improve bowel habits and minimize constipation. High fiber diet. Most Americans have a low-fiber diet, consuming way less than the recommended 20-35 grams of fiber per day. Fiber can come from dietary intake (the foods you eat) as well as supplements. Take the time to read labels. The foods we commonly think of as “high-fiber,” including lettuce, are not as fiber-rich as we think. A word of warning If you quickly add a significant amount of fiber to your diet, this can lead to gastrointestinal distress (gas, diarrhea, cramping, etc.). Add fiber slowly until you reach your goal! Stay hydrated! Fiber without adequate hydration will create hard stools (rabbit pellets), making constipation worse. The recommendation is a minimize of 64 ounces of water per day. Plain water is best, but flavoring with Crystal Light, lemon, or lime can make it more palatable. Listen to your body regarding bowel movements. Hold it until socially acceptable, but don’t hold for longer than necessary. But just as important, don’t force a bowel movement if you don’t feel the urge. Some people may be trained to try to have a bowel movement before leaving for work- if this works for you, that’s fine. But don’t let the clock dictate when you have to use the bathroom. Minimize the amount of time sitting on a toilet. Prolonged sitting increases pressure, which predisposes to pathology. If you are still having challenges, consider investing in a device to facilitate improving your posture. We are accustomed to using toilets…unfortunately, sitting creates an angle that makes it difficult to have a bowel movement. Squatting, with knees elevated closer to the chest, creates a straighter path leading to more optimal conditions to have a bowel movement. Consider a squatty potty! Specific Anorectal Pathology Hemorrhoids Anal Fissures Pruritis Ani Patient Info- Fiber Guide .pdf Download PDF • 68KB Patient Info- Hemorrhoids .pdf Download PDF • 58KB Patient Info- Anal Fissure .pdf Download PDF • 59KB Patient Info- Pruritis Ani .pdf Download PDF • 58KB Patient Info- Constipation .pdf Download PDF • 54KB Previous Next