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< 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

< 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

6 Tips to Be More Comfortable with Uncomfortable Conversations Giving Bad News < Back 6 Tips to Be More Comfortable with Uncomfortable Conversations It's not fun to tell families (or patients) that there was a complication, that their loved one died, or that their loved one is not going to survive. But it's a fundamental principle of good patient care, especially in the specialties of trauma and critical care. I didn't become truly comfortable with these conversations until my critical care fellowship. After many years and countless conversations in private rooms, here are my tips on how to develop this skill. 1. Experience. It's uncomfortable, but you should take every opportunity to participate in these conversations, starting as a student/ trainee. - As a young resident, I remember walking with my attending to go talk to a family about an intra-operative complication. I'll never forget the sinking feeling in my chest, the shame that I made a mistake. This was a pivotal moment in my training. My attending didn't have to tell me I messed up. But he knew I needed to see how he handled disclosing to the family members. He showed me that this wasn't something that I should allow to crush my self-confidence. - A few years later, during one of my first trauma rotations, I remember sitting in a small room in the ER as one of my co-residents told a family that their child was the victim of a fatal shooting. I didn't have much experience telling families that their loved one had died. In particular, I didn't have any exposure to telling a family that their loved one died in a trauma bay- a family I'd never met, a family who never had a chance to see their loved one before they died from their injuries. I was initially embarrassed that my co-resident, who was one year younger than me, was more comfortable leading the discussion than I was. But then I realized he had much more exposure to that type of conversation because of his previous trauma rotations. So I took it as an opportunity to learn and prepare myself to lead the conversation the next time. - Two years later, in the ICU waiting room of the same hospital where I watched my (younger) co-resident tell a family their son died, I sat with the mother of a young man who was critically injured. Thankfully, I had much better news. But still, it's not easy to tell a single mother that her oldest son was shot through the chest, and was laying in the ICU, intubated, with an open chest and abdomen. 2. Learn from watching experts. - Everyone has a slightly different style of handling these conversations. I joined my attendings for every conversation I had the opportunity to witness. This included conversations about everything from Code Blue incidents to fatal injuries and end-of-life care. It's important to see different styles, which will allow you to develop your style. Some are more blunt, some are more observant of family dynamics, some are overly talkative. There are some you may choose to not replicate, but it's important to see a spectrum of styles to learn what works for you. - I've watched my MICU attending talk with the wife of a man who came to the hospital with acute cardiac arrest, requiring emergent coronary angiography and intervention, then therapeutic hypothermia. I learned how to succinctly describe a complex situation and support a wife make a crucial decision without pressuring her. - I've watched my trauma attending talk to a family of a young male patient who had died on the operating table. I've watched that talk more than once, unfortunately. And it never got more comfortable. But I learned how to convey devastating news while simultaneously expressing compassion. 3. Practice. - As a fellow, I would often have a pre-brief with my attending and we would discuss key points for the meeting, as well as the goals of the discussion (ie deciding about proceeding with surgery, deciding about comfort care, etc). - When I have younger residents who are having family meetings, particularly one's that I haven't worked with before, I have them rehearse their conversations with me before. I did this as a resident and a fellow, and I still do this with my fellows. 4. Get feedback. Positive feedback is always nice, but true constructive feedback is key to improving. - I've had nurses and chaplains who have joined me for multiple family meetings, and it's always reaffirming to hear them compliment my interaction. - My attendings still occasionally joined me in conversations toward the end of my fellowship. It was always helpful to hear feedback about what was well-received and how I could have been more effective. 5. Once you've practiced, developed your style, and absorbed feedback- don't expect it to always be easy. - Towards the end of my fellowship, I had a particularly challenging case. I had already had countless family discussions and had become very comfortable with being uncomfortable. For a variety of reasons, I was emotionally overwhelmed with this patient's situation- I sat and cried at the nurse's station for a long time. Then I went and talked to my attending and told her I couldn't have the conversation, that I couldn't stop crying. I was hoping she would take over and lead the conversation- I should have known I wouldn't get off that easily. She reassured me that I wouldn't have to say much- I had already established rapport with the patient's family the day before, and they'd be able to tell from my non-verbal communication that I didn't have good news. It was (and still is) the hardest conversation I've had. 6. Don't Stifle Your Emotions (within reason) - Some people would criticize me for expressing emotion when having discussions with families. I do think there has to be a healthy separation, and getting emotionally invested with every case would be paralyzing. I don't cry during the majority of these conversations. However, I'm not a robot, and I still occasionally have patients that affect me on a more personal level. For example, I had one family that came to the very difficult decision to transition their mother to comfort care. Their mother was the matriarch of the family and her children didn't want to disrespect her. She had expressed that she would not want to be kept alive if she couldn't continue to have meaningful interactions and care for the family. I told them that giving them the implicit approval to allow her to die peacefully was probably the greatest gift she could have given them, and I reassured them that they were showing her the ultimate level of respect and kindness by honoring her wishes. That hit me differently because I could feel their pain as I imagined myself in their position. Previous Next

The emotional stress and challenges of ACS I could never do your job < Back The emotional stress and challenges of ACS René Leriche, “Every surgeon carries within himself a small cemetery, where from time to time he goes to pray—a place of bitterness and regret, where he must look for an explanation for his failures.” Acute Care Surgery is not an easy profession. My time as a surgical critical care fellow challenged me in ways I never predicted. The challenges of this field are numerous, although not all are unique to acute care surgery. Historically, trauma surgeons worked long hours (with the associated sleep disruptions), unpredictable workloads managing a mixture of high acuity critically-ill and injured patients, high patient mortality rates, and frequent exposure to horrifically injured patients.(1) Despite my intense desire to pursue this, I didn't truly grasp the depth of the emotional toll I would face. I am incredibly grateful to the mentors who guided me during my fellowship. I have told plenty of family members about the death of their loved one. There is a palpable difference between the interaction with a family of a patient you never knew- someone who came in unresponsive or someone who died shortly after arrival. It’s tragic, without a doubt, and it’s never easy to tell a family about this unexpected loss. But managing patients in the ICU, you have the opportunity to talk to them, to learn about them as real people, to meet their family. There are a few specific patients and family conversations I will never forget. After a busy week during the winter holidays, I was already emotionally drained. Friday morning, I sat in a large room full of family members and had to break the news that their loved one had become significantly sicker overnight. Unfortunately, he continued to deteriorate, and the following day, I had to tell them there was nothing else we could do. From my viewpoint, all human life is valuable. Sometimes it seems incredibly hopeless, which leaves us feeling helpless. It took me a while to gather myself for the second conversation with that same large family. I confided in my attending that I didn't think I could get through the conversation without tears. Thankfully, she gave me the gift of acceptance- she told me that I had established rapport with the family, and it was okay to cry. She also reminded me that I wouldn't have to give a long speech because they would already know that it wasn't good news. I am grateful for the opportunities I had to witness intense conversations between senior trauma surgeons and various critical care physicians and patients and families. I learned lots of critical care and patient management, the principles of managing multiple critically ill patients, and advanced operative techniques of trauma and emergency general surgery. But I am most grateful for the "art of medicine" that I learned from my mentors, which can't be taught in a textbook. Learning how to deliver bad news and help families navigate the difficult decision-making process are vital skills in this profession. This is a challenging specialty. It demands expertise in multiple clinical disciplines, the skill to manage multiple critically ill patients and the ability to balance contradictory needs of competing organ dysfunctions in one patient. Thankfully, with a good team of senior surgeons, you can navigate the nuances while training to practice this honorable profession. 1. The Committee to Develop the Reorganized Specialty of Trauma, Surgical Critical Care, and Emergency Surgery. Acute Care Surgery: Trauma, Critical Care, and Emergency Surgery. J Trauma. 2005;58:614 –616. Previous Next

The person you know her as isn’t there anymore Goals of Care < Back The person you know her as isn’t there anymore I have used those words on countless occasions while explaining severe/ non-survivable brain injury to patient's families. There are many phrases that providers use to describe end-of-life care. Palliative care. Palliative extubation. Withdrawal of care. Withholding of care.(1) Words are powerful, and conversations about the death of a loved one are remembered well into the future. What they hear can significantly impact their perception of how you are caring for their family or friend. Phrases such as “withdrawing care” can signal that the medical team is giving up and sticking their mother or child or best friend in a dark corner to die a miserable death. We aren’t withdrawing care- in reality, we are continuing to provide maximal patient care, following their wishes. Just because the result is death doesn’t mean we aren’t caring. Death isn’t pretty, and we shouldn’t pretend that we can eliminate the family's pain. But our approach to providing a peaceful dignified death with minimal pain and distress and anxiety can ease some of the family's distress. During my year of dedicated ICU training, I have guided countless families through the decision-making process of end of life care and several conversations will be permanently etched in my memory. I am grateful that I was able to witness and learn from some incredibly experienced and compassionate critical care physicians. While I can’t completely pull back the curtain on the details of these conversations or the specifics of treatment at the end of life, I will share some of the wisdom I gleaned. The patient is already being actively cared for when we have these conversations. Pain and anxiety are treated, bony prominences positioned and patients are turned frequently to prevent pressure wounds. The focus of the conversation is directed at relieving the emotional suffering and distress of the family and friends. Every conversation is different, and empathy and tact are paramount. Also, allowing time for people to express their thoughts is important. It allows them to unload what they are struggling with and also allows the team to tailor the discussion to address their specific concerns. Loved ones present a wide spectrum of emotions. Recognizing and validating these feelings is one way to reassure people that what they are experiencing is not abnormal. It's also a very important step in assessing their understanding of the gravity of the current situation, as well as developing a sense of what their wishes would be (ie mom was very independent and would never want to live like this, my husband writes and teaches, and he wouldn't want to exist if he can't interact in a meaningful way). Some struggle with guilt about unresolved disputes. Others struggle with the crushing sadness of unrealized dreams for their child. But one emotion and concern that is almost universal is guilt about deciding to proceed with comfort care. One such interaction that I will never forget was about the children who were wrestling with the thought of giving up and letting go of their mother who had a devastating brain injury after a car accident. Their respect and love for their mother made it challenging to reconcile with the reality that she wasn’t ever going to be the same person. They talked about how strong and independent she was, and how she would never want to exist in a state of complete dependence. As I sat quietly listening, I heard the words of one of my mentors in my head…”You are showing your love for your mother. This is a gift that you can give her.” We will never erase their feelings, but we can provide reassurance that they aren't inflicting pain and suffering on their family, but they are actually respecting their wishes not to live in this condition. One of the phrases I adopted during my training was “The person you know her (him) as isn’t there anymore.” Seeing flickers of movement, watching their chest rise and fall, and feeling the warmth of their skin can all give hope, that maybe with time and aggressive care, their husband will return to them, their child will wake up and smile at them. The invisible truth of a devastating injury often hides the reality. It is our responsibility and privilege to guide these families through what is likely to be one of the most heart-wrenching moments of their life and to show compassion in our conversation and our care for their loved one. We aren't withdrawing care- we care for our patients until they die, but our goals of care should shift to align with their wishes. Previous Next

Websites to Bookmark < Back Technology #1 Websites to Bookmark Working with PDFs PDF Converter. All the things you could ever want to do with a PDF. Create, convert, edit, split, combine, etc. How to add links to a PDF PDF Outliner . $4.99. Easily add a table of contents to facilitate searching large PDFs. Available on Mac. iAnnotate PDF . $9.99 Most user-friendly program to view and make notes on PDFs. Available on iPad. Designs 99Designs by Vista. Logos, website development, graphic design and more! I hired a designer to create my logo for my LLC. Tailor Brands. Inexpensive program to create a simple logo. I created my first logo with this company. Near endless variety. And you can download icons optimized for social media platforms (Facebook, Twitter, Instagram), application platforms (Apple and Android), and various other programs (Pinterest, Quickbooks, Etsy, Linkedin, Meetup, Youtube). Design Program- Canva. An incredible free resource for designing creative and eye-catching social media products- videos, posters, blog posts, logos, flyers, etc. I have made YouTube videos and book covers on this platform. Lots and lots of extra features in the subscription version. Miscellaneous Diagrams . Open-source software for diagram and flowchart creation. User-friendly program (website) for creating any diagram, flowchart, or table that you desire. I have used it for everything from creating clinical management algorithms to draft a PRISMA flow diagram for a systematic review. You can save templates and download the final products. Time and Date . Create personal calendars. Calculate the number of days between two dates. Embed a PowerPoint on your Wix site . A nice tool that I learned about while making this website. Grammarly. Proof-reading program. Available as an add-on for Safari, embedded application for Microsoft Word, and free-standing application on Mac. Calendly . Free online appointment scheduling software. How to: How to read a newspaper article behind a paywall - https://archive.is/ www.nytimes - archive.ph/paste the URL Previous Next

4 < Back Trauma Resources Society Guidelines American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) Best Practice Guidelines Imaging Management of Traumatic Brain Injury Management of Orthopaedic Trauma Management of Geriatric Trauma Massive Transfusion in Trauma Recognition of Child Abuse, Elder Abuse, and Intimate Partner Violence Palliative Care Western Trauma Association Algorithms. Evidence-based critical decision algorithms in trauma. Pediatric Trauma Society. Guidelines and educational resources. Brain Trauma Foundation Guidelines. Concussion, prehospital and surgical management of TBI, pediatric TBI, prognosis in TBI, combat-related head trauma. Joint Trauma System: Clinical Practice Guidelines. Evidence-based guidelines developed by subject matter experts from both the military and civilian communities. Tutorials ER-REBOA PLUS Catheter , Prytime Medical. Quick Reference Guide. ER-REBOA PLUS Convenience Kit. ER-REBOA PLUS Catheter, Instrutions for Use. ER-REBOA PLUS Catheter, Product Video. Videos and Lectures Joint Trauma System: Emergency War Surgery Course. Lecture series based on JTS CPGs and the Emergency War Surgery Book. Trauma in a Flash. Brief videos on trauma topics, hosted by the Arizona Trauma Association. American College of Surgeons Resources Resources for Optimal Care of the Injured Patient, 2014. Framework for developing a trauma system. Compares the different resources available at Level 1, 2, and 3 verified trauma centers. "An ideal trauma system includes all the components identified with optimal trauma care, such as prevention, access, prehospital care and transportation, acute hospital care, rehabilitation, and research activities. Guidelines for Field Triage of Injured Patients Recommendations of the National Expert Panel on Field Triage, 2011. Basic algorithm for triage of trauma patients based on mechanism of injury, physiologic criteria, and anatomic region of injury. Stop the Bleed. Trains non-healthcare providers in point of injury treatment for massive hemorrhage. AAST Resources Brief Topic Reviews. COVID-19, Aspiration, Blunt Cardiac Injury, Blunt Splenic Injury, Child Passenger Safety, Clostridium Difficle, ICU Illness, Wound Care Instructions, Field Triage, Epidemiology and Injury Prevention, Mechanical Ventilation, Pelvis Injuries, Rib Fractures, Sports Concussions, Thromboembolic Disease, Trauma Systems, TBI Rehabilitation. CME Opportunities. Meet the Masters, high yield journal articles, in addition to countless other resources. Some are free, and some are $25 for non-members. Virtual Grand Rounds. AAST hosts virtual grand rounds, a web-based educational series Acute Care Surgery Fellow Educational Resources. 67 Educational Modules for ACS Fellows. Created by the ACS Committee. ONLY accessible by ACS Fellows. Previous Next

< Back What happens in the trauma bay? A glimpse into the inner workings of a trauma activation The radio crackles and the paramedic's voice cuts through the din of the emergency department. “Doctor to the radio”. The clock already started and time isn’t on our side. “30s-year-old male, a gunshot wound to the right arm and left back. GCS 7. Highest heart rate 110, lowest blood pressure 80 systolic. 5 minutes out.” The management of trauma starts at the time of injury, with bystanders and dispatched first responders. Immediate interventions can be performed on the scene, which is followed by rapid transport to the hospital. En route, care continues to be delivered as needed (starting IV, giving fluids/ blood, maintain an open airway, etc). The hospital is contacted to prepare them for an incoming patient. Key details dictate the resources that are mobilized in response. There are no universal criteria for what constitutes each level of trauma activation, and different hospitals have unique designations for the highest activation (Trauma Red, Level 1, Code 1, etc). However, triage is designed to rapidly transport the patient to the most appropriate facility. An adult trauma code 1 is paged out to the trauma team. As the team arrives, the minutes before the patient arrives are spent relaying key patient details shared from the pre-hospital team. For a hypotensive patient or report of massive bleeding, massive transfusion is initiated. Chest trauma? Chest tubes, possibly open thoracotomy tray. Extremity wounds? Check that the tourniquets are ready. Team roles are assigned, and a plan is discussed. When the patient arrives, the pre-hospital team presents key data to the entire team. At one of the facilities I trained, there was a standardized presentation. It was organized, succinct, and appropriately relevant; the trauma team and the pre-hospital team both knew what information was to be shared. Pre-hospital team report Age (or approximate age), gender, mechanism, time of injury, significant event details (prolonged extrication, death on the scene, etc). Significant pre-hospital interventions and events (tourniquet time and location, intubation, change in mental status). Presence of IV access (size and location) and administration of pre-hospital fluids or medications. Highest heart rate, lowest blood pressure. Trauma Evaluation/ ATLS After the report, the patient is transferred to the bed and the primary and secondary surveys are performed. Primary survey- assess airway patency, adequacy of breathing (bilateral breath sounds, chest rise and fall), circulation (control active hemorrhage, assess pulses), disability (rapid neurologic assessment with GCS and pupil exam), and exposure (remove clothing to facilitate exam, make sure they get covered with blankets to minimize hypothermia). Concurrent with the primary survey, IV access is obtained, blood is drawn, and interventions are performed based on the findings of the survey. If there are no immediate life-threatening injuries on the primary survey, the secondary survey is performed, which is a comprehensive head to toe exam (see below), including log rolling the patient to examine their back. Common diagnostic testing includes commonly, patients undergo FAST (see vignette "Blast Injury "), chest x-ray, and pelvis x-ray. Based on hemodynamic stability and injuries, patients are then dispositioned to the operating room, radiology for further imaging, admitted to the ICU or floor for ongoing resuscitation, observation, consults, serial exams, etc. Secondary Survey Head/ ears/ nose/ throat- facial abrasions/ ecchymosis/ tenderness, periorbital edema/ ecchymosis, crepitus, open wounds, blood from nares/ ears. Tympanic membrane. Jaw occlusion. Neck- c-collar in place, obvious ecchymosis, abrasions, open wounds, tenderness. Chest- wounds, ecchymosis, tenderness, crepitus. Axilla- wounds. Abdomen- wounds, ecchymosis, tenderness Pelvis- stability, pain. Back- midline spinal tenderness/ step-off, ecchymosis, abrasions, wounds. Rectal- tone, blood on rectal exam. Extremities- sensation/ motor strength. Abrasions, wounds, gross deformities Vascular- carotid, femoral, DP/PT, radial pulses bilaterally. GU- perineal ecchymosis or wounds, blood at meatus. Previous Next

Learning how to live with an ostomy Peer Support < Back Learning how to live with an ostomy Acute Care Surgery can lead to a need for subsequent elective procedures, including ostomy reversals, abdominal wall reconstruction after open abdomen management, and various wounds. I frequently see young, healthy males with ostomies. Thankfully, most patients are great candidates for reversal. But there are a variety of reasons why patients can't undergo reversal, at least not immediately. Injury to the anorectal sphincter complex would put the patient at a very high risk of incontinence. Another possibility is when the ostomy was created in the setting of acute bowel perforation, with an undiagnosed underlying inflammatory process. Reversing an ostomy without further workup could be problematic. I have seen several young, healthy males who have to spend at least a handful of months with their ostomy while undergoing preoperative workup, and more than one who will likely have a prolonged or permanent ostomy. This can be daunting, especially when they were anticipating minimal delay before undergoing a reversal. Common concerns include how to wear normal clothes and how to manage the odor. While I can be supportive, I don't have any first-hand experience of living with an ostomy. One particular patient expressed a desire to return to college, but he was convinced that he couldn’t go to class with an ostomy. Essentially he was resigned to putting his life on hold until his ostomy was reversed. His situation inspired me to seek out a peer who could show him it's possible to live with an ostomy. I reached out to my network of medical personnel that might know how to connect a patient with a peer support group. We have multiple support groups, including trauma survivors, epilepsy, and stroke, to name a few. Unfortunately, I quickly realized there is no group or service to link patients with someone who will answer their questions and hopefully decrease their fears and worries. Many of the trauma patients who have an ostomy are young and healthy, leading active lives. Unlike elective ostomies, such as for inflammatory bowel disease, waking up after trauma with an ostomy is unanticipated and can be very distressing. Also, there is minimal or no chance for preoperative patient education. There is a certain taboo associated with talking about certain bodily functions, and I don't think many young males would ask their trauma surgeon if there is someone they can talk to about having an ostomy. But I think this could be an opportunity to improve the quality of life for a population that is likely overlooked. Previous Next