How to Adult Technology #1 Websites to Bookmark Technology #3 Video Tutorials Organizational Hacks How not to lose everything Kitchen Hacks #2 Measuring Cups and Spoons Kitchen Hacks #4 Favorite Websites and Apps Starting a Business Tips and Tricks from a Novice Technology #2 Mac, Microsoft and PDFs My Favorite Things Gadgets and Tools Kitchen Hacks #1 Meal Prep: Eating with Intention Kitchen Hacks #3 Common Measurement Conversions Kitchen Hacks #5 Ratios

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

< 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

Give me that thing that does the thing… Kelly Snap Mosquito < Back Give me that thing that does the thing… I don’t remember the names of all the instruments in the surgical tray. I swear they have a unique name for each size of the same instrument. Hemostats- crile, snap, stat, mosquito, tonsil, Kelly, Rochester Pean. There is a laundry list of pickups of different shapes with different teeth. And then throw in the culture of different hospitals and specialties. When you place a Bookwalter and you want the short wide curved retractor…do you call it a bladder blade or a curved body wall? And the straight one…is that a Rich or a body wall? In case you’re wondering, the curved retractor is called a Balfour and the straight retractor is called a Kelly. When you’re doing a laparoscopic cholecystectomy, do you ever ask for a wavy grasper or do you call it a prestige? Or something else altogether? As I resident and attending, I used a wavy grasper . Check out the picture. Doesn’t it look like…a wavy? When I was in fellowship, the same instrument was called a prestige. Sounds unnecessarily boastful to me, but whatever. After 9 years using a wavy, it was hard to break the habit and call it a prestige. Thankfully, the scrubs knew what I wanted. I found out it's actually called a Prestige Style Atraumatic Wavy Grasper , so it turns out, we are both right. But that would take way too long to say each time you want to grasp the infundibulum. As we move through training, we develop routines, including our favorite instruments to use during different steps of the operation. When surgeons and scrub techs spend time together during cases, they frequently develop a rhythm, a shorthand. A good scrub tech knows what you want before you even ask. I have had the fortunate of developing several relationships like this. My favorite scrub tech was Kelly. She was a fantastic tech, but also a fantastic person. And the joke of asking for Kelly Kelly never got old. After years of working together, she understood my style and my technique, and always had my next instrument ready. To be honest, it didn’t take years. She knew what I wanted, even if I asked for the wrong thing. She was an invaluable asset to the team, and I miss working in the OR with her. As I mentioned, I don’t remember the names of all the instruments in the surgical tray. A good scrub tech gives you what you want, not what you ask for. While operating, I often extend my hand toward my scrub tech, and as I’m trying to come up with the right name, I start to make gestures with my fingers. Fingers posed like holding a pencil signals scalpel. Thumb and index finger pinched together is my gesture for pickups. Index and middle finger in an open/close motion indicate scissors. Curved fingers, like holding a cup, means I want a retractor. And I request a needle driver by holding the scalpel pose and moving my wrist through a suturing motion. There have been many innovations brought about by the COVID pandemic, and I predict that business will never be conducted the same as before this era. The protective gear worn to prevent viral transmission negatively impacts team communication. This was one of the summary findings of a survey of surgeons, recently published in the World Journal of Surgery.(1) The impact on speech discrimination has been quantified in an experiment with a simulated noisy background.(2) Google “communication impediment COVID protective equipment” and you will encounter many publications regarding the unintended consequences of interventions designed to keep health care personnel safer. Before the pandemic, we already operated wearing masks, which eliminates some of the visual cues of communication. But novel respirators can add several hindrances, including restricting normal jaw movement and muffling the spoken word. The use of the PAPR (powered air-purifying respirator) added a whole new dimension- noise from the fan and battery adds a remarkable hurdle when the surgical team is trying to communicate with other members of the operating team. Admittedly my system is imperfect, and I think a universal sign language for the operating room is a brilliant concept. A proposed system was recently published in the British Journal of Surgery.(3) Signals were developed to request a scalpel, various retractors, forceps, needle drivers, and gauze. This concept is logical, although admittedly, I have become increasingly reticent to accept any innovation just because it appears simple and absent of downsides. Consider the intubation boxes that were developed to prevent aerosol dissemination early in the pandemic. The concept was rational- solid barrier to isolate the patient, great idea! But during simulation, there were multiple hurdles- largely, it makes difficult intubation more challenging, which potentially defeats the purpose by increasing maneuvers and personnel and time to successful intubation. To quote one review: “Well-designed simulations…should always be used to test medical innovations before implementation... “Face validity” alone should not be the basis of innovation adoption.”(4) Is a new language necessary? Do we really need a system to talk to the tech, who is standing closer to us than anyone else in the room, and probably already knows what we want? They are more focused on exactly what is going on in the operative field than anyone else, and they can lean closer or ask us to repeat our request. We need a better way to talk to everyone else in the room! The anesthesiologist who is balancing multiple tasks and the OR nurse who is at least several steps away from the surgeon. What are the potential roadblocks or negative consequences associated with implementation? · Potential for misinterpretation of signals…someone is expecting a pickup and they’re handed a scalpel, which is quickly brought into the field and creates an injury. · The inability of the surgeon to create the signal if both hands are working. · If verbal communication is eliminated, the tech has to constantly watch the surgeons hands, which prevents them from doing other manual tasks, such as loading clip appliers, returning needles to the count box, receiving freshly opened materials from the scrub nurse, etc After all that, I’m not rendering a final verdict. This is an innovative and intriguing concept with a lot of potential. It should be considered and trialed while ensuring that its benefits outweigh the negative impacts before wide-spread implementation. 1. Yánez Benítez C et al. Impact of Personal Protective Equipment on Surgical Performance During the COVID-19 Pandemic. World J Surg. 2020 Sep;44(9):2842-2847 . 2. Hampton T et al. The negative impact of wearing personal protective equipment on communication during coronavirus disease 2019. J Laryngol Otol. 2020 Jul;134(7):577-581 . 3. Leyva-Moraga FA et al. Effective surgical communication during the COVID-19 pandemic: sign language. Br J Surg. 2020;107(10):e429-430 4. Chan A. Should we use an “aerosol box” for intubation? Life in the Fast Lane. 2020 Jul. https://litfl.com/should-we-use-an-aerosol-box-for-intubation/ Previous Next

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

Tips and Tricks from a Novice < Back Starting a Business Tips and Tricks from a Novice *Disclaimer* This is all information from my own personal experience. The materials available on this website are for informational purposes only and not to provide legal or financial advice. Please consult a legal or financial expert to obtain advice for any particular issue or problem. TL;DR Choose what type of business entity to start- *research the legislation of your particular state* Register your business name Request EIN Download copies of tax forms Identify NAICS Open business bank account Create template forms- invoice, contract, waiver, receipt, etc Create a spreadsheet for tracking inventory, invoices, payments, etc Save all paperwork and receipts Create standard language for email communication (responses to inquiries, replies to potential clients, advertising messages, etc) and a standard signature block. Maintain consistency- logo, colors, language, font, etc. A few months ago, I embarked on the journey of starting my own business. Before I started this endeavor, I knew very little about business- I knew about limited liability companies (LLC) because my dad has his own LLC. I started my search from scratch, literally googling different derivatives of "business owner". Here's what I found out in my research and while I was creating my own sole proprietorship. There are a few different types of business ownership, including sole proprietorship, partnership, corporations, and limited liability companies (LLC). Specifically, individuals can form an LLC or create a sole proprietorship. These different entities vary based on their reporting requirements, paperwork, etc. Business regulations are not standard nation-wide, so you need to research your state regulations. I eventually decided to proceed with a sole proprietorship. One of the key differences between a sole proprietorship and an LLC is the distinction between the business and the owner. **Remember, it's important to do your research on the laws in your state. ** An LLC theoretically offers more protection- the general principle is that an LLC is separate from the owner. If an LLC is sued, they can't access your personal assets. A sole proprietorship doesn't offer the same boundaries. Sole proprietors have a single owner with complete control over the business, including profits and business decisions, and that individual is also responsible for all debts. The sole proprietorship is not a separate entity from its owner, and therefore it is not taxed separately. In other words, sole proprietors report income and expenses on the proprietor's federal individual income tax. One piece of advice I was given is that an LLC gives more credibility to your business. Personally, I don't think my clientele will be more likely to work with me if I added the designation "LLC" to my business name. In my opinion, given the nature of my business, my medical credentials/ board certification/ degrees are the biggest source of my credibility. MD, FACS, board-certified, etc- these mean something in the medical community. To create a sole proprietorship, I registered my business name and requested a federal employer identification number (EIN). An EIN is not required by the Internal Revenue Service (IRS) for a sole proprietorship- I don't think it's required on my tax forms. However, all the banks I contacted require an EIN to open a business bank account. After registering my business name, I downloaded copies of the tax forms that are required. It helped me understand what would be expected when filing taxes. Much less intimidating than waiting until tax time. Next, I identified my business category as described by the North American Industry Classification System (NAICS). The NAICS is comprised of many categories and sub-categories of business industries, such as construction, utilities, food services, arts and entertainment, real estate, or education. According to the IRS website "NAICS is frequently used for various administrative, regulatory, contracting, taxation, and other non-statistical purposes…Some contracting authorities require businesses to register their NAICS codes, which are used to determine eligibility to bid on certain contracts." Personally, I was required to identify my NAICS when I opened my business bank account. The next step is opening a business bank account. A separate bank account is necessary to distinguish your personal business income from your wages (if you have another job). First, you have to make sure your bank supports business accounts. For anyone who uses USAA for your banking needs, please take note that USAA does NOT support business accounts and you'll need to establish an account with another bank. The process of meeting with a bank manager to set up my bank account was very educational- I learned about the difference between ACH, quick deposit, and wire transfers. Those are the initial steps to having a legitimate business. The next few things help boost your credibility by creating a distinct brand. I initially had one website, which was mostly educational, with a single page for my business. My moniker evolved naturally- docrot was my username in medical school. This eventually morphed into Doc on the Run, which has been my Instagram name for years and became my Twitter handle over a year ago. Initially, my business name was "ABS-CE Prep with Doc on the Run", which was my moniker. Eventually I scaled this back to ABS-CE Prep. While I was still "ABS-CE Prep with Doc on the Run", I decided to make a logo. I used Tailor Brands , which is a user-friendly platform for developing a unique branding and logo. I chose an icon and font to create a simple but distinct logo. Consistency is important. As mentioned in my website creation post, I used the same color scheme for my logo and my website. Using a 6 digit hex code ensures that my blue text and red icon in my logo are the same as the red and blue on my website. Next, depending on your business, you will likely require at least a few standard forms. My business is service-based. I needed a template for invoices and receipts, as well as a standard contract/ waiver to be signed before beginning sessions with a client. Prior to my business name change, I used my logo on each form. Finally, if you still have questions, I recommend consulting a lawyer or business expert. Previous Next

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

< Back Interpreting Chest X-Rays Developing skill with radiographic interpretation requires practice. Look at every film for your patients. Practice by looking at normal films, then compare between normal and abnormal. For example, compare an image for a patient with a normal cardiac silhouette and compare it with a patient with an abnormal silhouette with a widened mediastinum. This is NOT an exhaustive list of everything that can be seen on a chest x-ray, but is an overview of common pathology that can be seen. How to read a film 1. Identify- correct patient/ date/ time. 2. Identify orientation. Is the projection posterior-anterior (PA) or anterior-posterior (AP)? Is the patient rotated? PA is when the patient stands with their chest facing the x-ray cassette and the x-ray is behind the patient, so the x-ray beam travels from the posterior of the patient toward the plate, which is situated on the patients anterior surface. AP is when the patient’s back is towards the board and the x-ray is in from front of the patient, so the x-ray beam travels from the anterior of the patient toward the plate, which is situated on the patient’s posterior. This is the orientation when a patient is laying supine in the trauma bay. On an AP film, the heart appears enlarged compared to the PA. Rotated- compare bilateral or midline structures, such as clavicles and the spinous processes of the vertebra. If the clavicles are asymmetric or the spinous processes are not midline, the patient is rotated. Structures (ABCs) 1. Airway Is the trachea midline? Are there any opacities in the lung fields- pneumonia, masses, bilateral haziness? Do the lung markings extend to the edge of the chest? If not, and the space area is dark, this is suggestive of a pneumothorax. In contrast, if the space is white, this is suggestive of a fluid collection (hemothorax, infected fluid, etc). Is there evidence of fluid? This depends on the patient’s postion and the consistency of the fluid. Free fluid (fresh hemothorax, pleural effusion) will layer dependently, so if the patient is upright, the costophrenic angles will be blunted. If the patient is supine, the fluid can cause generalized opacity of the lung field because it layers along the back of the patient. 2. Bones- examine for fracture, dislocation, masses (tumor) Upper extremity/ shoulder? Ribs? Vertebra? 3. Cardiac Silhouette size/ contour? Normal is <1/2 the size of the thoracic cavity Evidence of aortic injury? *Bonus- 3 places for blunt aortic injury- aortic root, diaphragm, and isthmus just past subclavian takeoff Widened mediastinum (supine >8 cm or upright > 6cm) Loss of aortopulmonary window Abnormal aortic contour Depressed left mainstem bronchus Left apical capping Left hemothorax Nasogastric tube deviation Widened paraspinal or paratracheal stripe 4. Diaphragm Elevated- symmetric elevation is consistent with poor inspiratory volume. Blunting of costophrenic angle- effusion. Abdominal contents in chest (ie gastric bubble in the left chest)- consistent with diaphragm injury or defect. 5. Everything else Air in soft tissue- many potential etiologies, but common causes include pneumothorax or esophageal/ airway disruption. Air under the diaphragm (pneumoperitoneum)- concerning for hollow viscus injury. Iatrogenic foreign bodies- endotracheal tube, central lines, ports, pacemaker, endovascular grafts, esophageal stents, feeding tubes Non-iatrogenic foreign bodies- swallowed objects Additional References and Images from Radiopaedia.org **Click on Cases and figures and Imaging differential diagnosis on the right-hand column of each page for more in-depth explanations of specific pathology** Radiopaedia Airway Bones and Soft Tissue Cardiac Silhouette and Mediastinum Widened Mediastinum Hemothorax Pneumothorax Nasogastric Tube Position Previous Next

< Back Bowel Anastomosis A handsewn small bowel anastomosis can be created end to end or side to side. When creating a side to side anastomosis, the planned enterotomy site on each limb of bowel is identified. The backwall is created first, just lateral to the planned enterotomy sites- it would be very challenging to access this portion of the anastomosis after creating the inner layer. The back layer is followed by inner layers of absorbable suture. My personal preference is Vicryl, but PDS can also be used. Finally, the anterior outer seromuscular layer of silk is created. Posterior outer layer of interrupted 3-0 Silk Limbert sutures Posterior inner layer of interrupted 3-0 Vicryl sutures Anterior inner layer of Connell with 3-0 Vicryl Anterior outer layer or interrupted 3-0 Silk Limbert sutures Inner layer of absorbable sutures and outer seromuscular layer of silk. Two different depictions of side to side anastomoses (1,2). Rao SD. Small Intestine, In: Snapshots in Gastroenterology. Jaypee Brothers Medical Publishers (P) Ltd. 2016. Rao SD. Pre- and Postoperative Management in Midgut (Small Bowel) Surgery, In: Gastrointestinal Surgery Step by Step Management. Jaypee Brothers Medical Publishers (P) Ltd. 2005. Previous Next

How to play nice in the sand box...and why it matters Consults < Back How to play nice in the sand box...and why it matters The department of Acute Care Surgery and Emergency Medicine frequently interact to discuss consults. Unfortunately, several factors predispose to an adversarial relationship between the ER provider and the consultant.(1) I won't pretend that I didn't contribute to some of the negative interactions I've had while responding to consults. However, I'm grateful that my years of experience have provided me with insight and perspective that reframed my thoughts about the consultation process. What are the different types of consults? #1 The patient requires something that is beyond the scope of practice of the emergency provider. This includes everything from hospital admission, surgical or procedural intervention (appendectomy, stop the bleeding from a penetrating neck wound, cardiac catheterization), or a plan for close follow-up. How to Respond? This is why we chose our specialty, and our business is patient care. If a consultant is not responsive, it might be because they are caring for more urgent clinical issues. It's also possible that they are a generally unpleasant person, and it has no relation to the nature of the consult..some people can be difficult regardless of the scenario. Admittedly, it might also be 2 am, and they just fell back asleep after their last page. As much as I hate to admit, it's harder to be pleasant on the phone when you're absolutely exhausted. #2 The unclear diagnosis. The patient is presenting with a complex issue, or the diagnosis may be outside the provider's experience. This could be the first time they encounter a particular clinical scenario or an unusual presentation of a common diagnosis. How to Respond? Depends on the scenario. If that patient requires emergent assistance, prioritize their needs. If no emergent need, but further workup is needed, provide whatever recommendations you can regarding the next steps of the diagnostic workup. If the patient's case falls under your specialty, refer back to #1. #3 The emergency room provider doesn't know who the appropriate consultant is, or they have had no luck reaching them. How to Respond? It's easy to brush off a call when the primary provider called the wrong service. This might occur if the provider cannot reach a particular specialist, and you are the next best option (example- plastic surgeon doesn't respond for a consult on a patient with a wound complication). Please, if you know how to reach that provider, lend a hand. Or, if they call the wrong service, take the time to give a little guidance about whom they should have called. They aren't trying to waste your time- they are likely also busy, and calling multiple consultants is not the best way to spend their time either. Whatever assistance you can provide is best for the patient. #4 The controversial consult. In my experience, during years of working with surgeons and emergency physicians, probably one of the most contentious consultations is the consultation for something that the consultant considers inappropriately simple or unnecessary. The surgeon may think that the issue is trivial or the need is non-existent and feel that the provider should be capable of resolving the issue without calling a surgeon. This disconnect might be the key patient interaction that can set the tone for the relationship between departments. How to Respond? First, and most importantly, please don't be dismissive when someone calls you for a consult. If you are receiving a call, it's because the person on the other end of the phone (and therefore the patient they are caring for) needs your help. Surgeons, along with other specialists, have extensive specific expertise, so it's easy to lose perspective and presume that the knowledge in our head is universal. It's become almost intuitive in our minds, so we might forget that the primary provider does NOT have the same specialization. We each chose our respective specialties, and our training and biases are quite divergent. It is unreasonable to expect ER physicians to share the same depth of knowledge in each of the many specialties, just as each of the specialists would not have the same ability to deftly juggle the wide array of clinical scenarios managed in the ER. I remember the plastic surgeon who showed me how to do a scar revision on a young woman's face. He spent his career training and practicing to perform plastic surgery. It was simple in his hands, but that doesn't mean the woman would have a similar outcome if the needle driver was in my hand. Please, think of the patient's best interest. Yes, the primary provider may be "an idiot" or "lazy" or whatever. But consider the other possibilities. I prefer to give my colleagues the benefit of the doubt and avoid automatically assuming incompetence. Regardless of the underlying issue, whether it's a flaw of the provider or its truly beyond their capability, the patient needs someone to take care of them. Do the right thing for the patient- in the end, that's what matters. 1. Koo A, Bothwell J. Tips for Working with Consultants. ACEP Now. Nov 2017. Previous Next

< Back Tips and Tricks General Tips Despite popular belief, you don’t need a daily CXR for every ICU patient, every intubated patient or every patient with pneumonia/ rib fractures. Don't get daily labs or daily imaging "just because". Get studies that will change your management. For stable patients, you don’t need to check a CBC immediately after every transfusion. You don’t need a PaO2 to wean FiO2. PaO2 is an infinitesimally small contribution to arterial O2 concentration. The equation is often simplified by removing it all together! CaO2= (Hgb x SaO2 x 1.38) + (PaO2 x 0.03) ≈ (Hgb x SaO2 x 1.38) Avoid adjusting multiple meds at one time when addressing a symptom (for example, adding a new medication and increasing the dose of another medication). Too many changes at the same time will make it difficult to know what medication change was responsible if there is a clinical change. Most patients don’t need a CXR after chest tube removal. If the pt has PTX that requires a chest tube, they will tell you (meaning they will be symptomatic). If you check a CXR on everyone, you will find small PTXs that don't need treatment. Not everything that hurts/ bleeds is a hemorrhoid. Exam is required to identify the etiology. If you treat a fissure with hemorrhoid meds (witch hazel, suppositories) they won't get better. Plus, witch hazel will burn and suppositories will be incredibly painful. Patients often get better despite us, not because of us. Many things we believe to be optimal treatment now will be considered heresy in the future. Sometimes not doing something is the best thing to do. Sometimes not operating is the compassionate thing for the patient. A patient doesn’t have to die with an incision on their abdomen. Working with your team Trust the nurse when they say they’re concerned. Better to have a phone call for a patient who is ultimately fine vs not getting a call when the patient isn’t fine. If you respond to nurses by telling them it’s fine and not to worry, they will learn not to call you. If you respond to nurses with hostility, they won’t go out of their way to make your life easier. Don’t call your mid level resident/ chief/ fellow/ attending without any more information than you were initially given. When requesting a consult or calling your chief/ fellow/ attending about a new consult/ admit, give the bottom line upfront. This is especially true when you are waking someone up or need them to do something quickly (ie get dressed and drive in). Tips for the OR While closing fascia, if you maintain counter-traction on the fascia with your pickup as you pass the needle through the fascia, you can release the needle while it’s still in the fascia and reload the needle farther back to push it the remainder of the way through the fascia. Then you can reload the needle and be ready for your next bite without having to touch the needle (decrease risk of needle sticks). Ask for instruments and sutures several steps ahead so you minimize pauses. Always ask for cell saver for a bleeding patient heading to the OR. You don’t want to be delayed waiting for it to be set up before you make your incision. Tips in the Trauma Bay Don’t use GCS 8 as an automatic trigger for intubation. If you intubate before addressing hypovolemia or relieving obstructive physiology, there is a high risk of cardiovascular collapse and asystole. Previous Next

< Back Blast- Multiple Penetrating Injuries A 32-year-old male soldier sustained a severe blast injury with a chest wound and a supraclavicular wound, a tangential right shoulder wound, and right hand wounds. He arrives at the hospital for care. He was awake and alert, hemodynamically normal. A secondary survey revealed these wounds. Injury Pattern What are the possible injuries based on this wounding pattern? Intra-thoracic (cardiac, pulmonary), great vessels/ right subclavian vessels Next steps in evaluation? Extended FAST exam to evaluate for fluid in chest, abdomen, and pericardial space. CXR to identify for retained foreign body. Helpful to place radio-opaque markers on wounds to help establish trajectory. Plain film of chest/ upper abdomen What additional injuries are possible based on these wounds and imaging? Any organ in the path of the wounds can be injured- this includes intra-abdominal structures (small and large bowel, stomach, spleen, kidney), retroperitoneal structures (kidney) and the diaphragm. How do we determine which body cavity to explore first? Hemodynamic stability and wounding pattern can direct how to proceed. A hemodynamically unstable patient requires swift intervention concurrent with ongoing resuscitation, while a stable patient can be approached more deliberately. The clinical exam can suggest which body cavity is causing the instability. Peritonitis, abdominal distension, grossly positive FAST in the abdominal views suggest the abdomen as the site of injury. Signs of thoracic injury causing instability include decreased breath sounds, jugular vein distension, muffled heart sounds, fluid on pericardial view of the FAST fluid, and a large volume of bloody output in the chest tube. In addition, location of projectiles on plain film help determine trajectory, and any structures along the trajectory can be injured. This patient was managed in a deployed environment by an austere surgical team. We did not have access to CT imaging and we had limited capacity for continuous monitoring. Therefore, in order to rule-out cardiac and intra-abdominal injuries, we performed a midline laparotomy. We performed a pericardial window through the laparotomy. There was no fluid in the pericardium. We performed an abdominal exploration. There were no intra-abdominal injuries. Wounds in the Cardiac Box In the classic description, the “cardiac box” is bordered superiorly and inferiorly by the sternal notch and the xiphoid process, and laterally by the nipples. However, thoracic gunshot wounds outside these confines can just as readily result in a cardiac injury. The diagnosis of cardiac injuries starts with a physical exam and FAST. Physical exam findings can include hemodynamic instability, muffled heart sounds, and jugular venous distension (Beck's triad). FAST will reveal pericardial fluid. If the patient is awake, they may be panicked and have an impending sense of doom. Penetrating cardiac injuries require operative repair. FAST Examination Online Tutorial Society for Academic Emergency Medicine SAEM FAST Exam YouTube Video Previous Next