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< 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

< Back Pruritis Ani What is Pruritis Ani? Patient information: Pruritis Ani [American College of Colon and Rectal Surgeons] Pruritis ani is an unpleasant itching of the perianal skin (around the anus). Scratching can lead to further irritation and sets up a vicious cycle. Caused by other anorectal diseases, primary dermatology conditions, hygiene issues (sweat, stool, mucus on the skin), foods, soaps, clothing, or over-vigorous hygiene (aggressive wiping with rough material, use of topical cleaning agents). Diagnosis- detailed history, thorough exam to rule out underlying anorectal pathology What is conservative management for pruritis ani? Try not to scratch/ wipe/ scrub. It will just itch more, and things will get worse. Clean the anal area after bowel movements with hypoallergenic personal wipes. Do NOT over clean, as this may worsen your condition. Dry with a hairdryer on the cool setting instead of wiping the area dry. Use unscented Dove soap or dilute white vinegar for cleansing. AVOID potential contributing factors Citrus foods, caffeine-containing foods/ beverages- coffee, tea, cola, chocolate. Scented soaps, lotions, creams, powders, medicated wipes, witch hazel. Keep the area dry (can use cotton ball or a gauze pad). Avoid tight synthetic clothing that doesn’t breathe. Wear cotton undergarments. Maintain regular bowel movement with normal consistency (minimize stool leakage). Increase stool bulk by increasing fiber intake. Maintain adequate hydration- you MUST drink at least 64 ounces of fluid per day, in addition to increasing fiber intake. Medication Capsaicin- causes a low-grade burning sensation and decreases the perception of itching Zinc oxide- Apply a small amount of a barrier cream to the perianal skin in a thin layer. This will protect the skin from irritants. Mix Benadryl cream with the zinc oxide cream and apply it to the affected area. Benadryl- 25 mg by mouth at night for itching Patient Info- Pruritis Ani .pdf Download PDF • 58KB Patient Info- Fiber Guide .pdf Download PDF • 68KB Previous Next

Mac, Microsoft and PDFs < Back Technology #2 Mac, Microsoft and PDFs Mac Keyboard Shortcuts Close application= ⌘ + Q Switch between applications= ⌘ (press + hold)+ Tab (press + release) Screenshot (whole screen/ part of screen)= Shift + ⌘ + 3/ Shift + ⌘ + 4 Record your computer screen= Shift + ⌘ + 5 Page up/down= FN + up arrow/ down arrow Jump to top/bottom of document= FN + Command + left arrow/ right arrow Undo/ redo= Control + Z/ Control-Y Select all= Command + A [⌘ + A] Copy/ paste highlighted text= Command + C/V [⌘ + C/ ⌘ + V] Finder New Finder Window= Command + N [⌘ + N] Close All Open Finder Windows= Command + Option + W [⌘ + ⌥ + W] Safari Autofill Webpage= Shift + Command + A Switch between tabs= ⌘ + 1 (2, 3, etc) Microsoft Word Bold/ italicize/ underline highlighted text= ⌘ + B/ ⌘ + I/ ⌘ + U Add hyperlink= ⌘ + K Expand all hyperlinks (Word)= Fn + Opt + F9 Insert footnote/ endnote= ⌘ + ⌥ + F/ ⌘ + ⌥ + E Microsoft Excel Select all cells= ⌘ + A Select row= Shift + Space Select column= Ctrl + Space Hide rows/ columns= ⌘ + 0 / ⌘ + 9 Edit text in active cell= Ctrl + U New line of text in active cell= ⌥ + Return Format currency/ percentage= Ctrl + Shift + $/ Ctrl + Shift + % Insert current time= ⌘ + ; Insert current date= Ctrl + ; Links for How-Tos Mac keyboard shortcuts Create keyboard shortcuts for apps on Mac Microsoft Tips and Tricks Microsoft Word Keyboard Shortcuts Make different lines View all Abbreviations in a document Create and format a customized list style Save the current list style as a template to use in other documents Changing Level in a List Create embedded bookmarks and hyperlinks Format an image to be integrated with text versus between sections Change Text Formatting Microsoft Excel Keyboard Shortcuts Count cells- empty, data, specific data Combine text from multiple cells Highlight cells with specific data Creating a customized drop-down list Create a dependent customized drop-down list Microsoft PowerPoint Add Text to the slide background of a PowerPoint presentation Center an image Portable Document Format (PDF) [Mac Only] Combining PDF Documents Combining PDFs in a specific Order Modifying PDF Documents Microsoft Tips and Tricks .pdf Download PDF • 2.77MB 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

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