< 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 Stomach Ulcers UpToDate Patient Information Patient education: Peptic ulcer disease (Beyond the Basics) Patient education: Helicobacter pylori infection and treatment (Beyond the Basics) Patient education: Upper endoscopy (Beyond the Basics) Patient Information from Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Upper Endoscopy Previous Next

< Back Anal Fissure What is an anal fissure? Patient information: Anal fissure [American College of Colon and Rectal Surgeons] Patient education: Anal fissure (Beyond the Basics) [UpToDate] Trauma from hard stool (constipation) creates a tear in the anoderm distal to the dentate line. Pain leads to internal sphincter spasm, setting up a vicious cycle! Symptoms- severe pain during and immediately following a bowel movement ("like pooping glass", "passing a razor blade"), blood on toilet paper with wiping. This often leads to fear of having bowel movements. Pain leads to muscle spasm→ higher pressure→ vicious cycle. Diagnosis- classic history is almost enough, but pain with effacement of the buttocks and visualization of a tear in the anoderm confirms. Don’t torture them with a digital rectal exam! On exam, typically seen in the posterior midline. If a fissure is seen in a different location, consider IBD, trauma, infection (Tuberculosis, sexually transmitted diseases), cancer. Source: UpToDate Images: Anal Fissure Anatomy What is conservative management for an anal fissure? See “ Anorectal Disease: How do I prevent anorectal disease? ” Improving bowel habits is the first-line treatment for an anal fissure. See patient handouts below. The majority of patients with an acute fissure heal with conservative management. If a fissure has been present for a long time, it is less likely to heal with conservative therapy. Sitz baths- fill a tube with water as warm as you can tolerate, and soak your bottom after every bowel movement and at least 3 times per day. Topical compounds- nitrates, calcium channel blockers→ relax muscle→ improved blood flow→ allows healing. Local anesthetics can also improve symptoms during the healing process. Avoid suppositories, Tucks pads, and Preparation H. These would be painful and won’t treat the disease. This is why diagnosis is vital. Patient Info- Anal Fissure .pdf Download PDF • 59KB Patient Info- Fiber Guide .pdf Download PDF • 68KB What is the operative management for an anal fissure? For the few patients who fail a trial of conservative therapy, surgical intervention can provide relief. Botulinum toxin (Botox) blocks neuromuscular function leading to muscle relaxation. Yes, this is the same Botox that is used to treat wrinkles. Low risk of complications. Lateral internal sphincterotomy is the treatment of choice for chronic fissures that have failed to resolve with other interventions. More successful healing compared to other interventions. Risk of incontinence (inability to control the passage of gas and stool). If incontinence occurs, the inability to control gas is more common than the inability to control liquid stool, which is more common than the inability to control solid stool. Previous Next

< Back Postoperative hypotension A 35-year-old male is in the ICU following emergency surgery for a small bowel obstruction. On arrival to the ICU, he has the following vital signs: HR 115, BP 85/40, SpO2 98. He underwent a 4-hour open lysis of adhesions. He received 2L of crystalloid and made 50 mL of dark urine, and did not require any medication to improve his blood pressure. He remains intubated and sedated. What is the differential for his hypotension? Hypovolemia- under-resuscitation relative to the insensible losses from open abdomen and likely preoperative dehydration Sepsis- bacteremia from gut translocation from small bowel obstruction, pneumonia from aspiration due to obstruction Tamponade, tension pneumothorax- did he have any intra-vascular devices placed in the OR? Pulmonary embolism- lengthy surgery, did he have appropriate mechanical prophylaxis? Cardiomyopathy The surgical team reports that he has not been tolerating a diet, or even liquids, for the previous 3 days. He received perioperative ertapenem for surgical infection prophylaxis. There was no evidence of aspiration during intubation and his admission CXR was unremarkable. He had a right internal jugular central line placed intra-operatively. He had no issues with oxygenation/ ventilation or high airway pressures intra-operatively. How can you diagnose shock and differentiate between the different potential etiologies? Physical exam- evaluation of skin turgor/ color/ temperature and mucous membranes, evaluation of fluid status (open wounds, nasogastric tube output, passive leg raise), examination of urine quality, auscultation of heart/ lungs Labs- cultures, complete blood count, lactate, liver function tests, BUN/Cr Ultrasound- gross evaluation of heart function, lung sliding to rule out pneumothorax, volume and collapsibility of the inferior vena cava Test for fluid responsiveness- based on stroke volume variation (SVV, see below), or response to passive leg raise or a fluid challenge. On exam, he is tachycardic without murmurs, lungs have equal air movement bilaterally. His nasogastric tube remains on suction with ongoing high output of gastric contents. On ultrasound, he has bilateral lung sliding. His cardiac contractility looks grossly preserved. He has normal oxygenation. His inferior vena cava is collapsible. He has a known source of infection (positive blood cultures), leukocytosis, elevated lactate, high fluid losses with evidence of fluid responsiveness. Shock: Undifferentiated Hypotension Hypotension ≠ shock. So what is shock? Inadequate perfusion to maintain end-organ function Pathophysiology: effective perfusion requires adequate cardiac output (CO). CO is the volume of blood that the heart pumps each minute, and it depends on stroke volume (SV; the volume of blood ejected with each heartbeat) and heart rate (HR; the number of heartbeats per minute). SV depends on preload (intra-vascular volume returning to the heart), myocardial contractility, and afterload (systemic vascular resistance). Shock is a disruption of preload, contractility, and/ or afterload. Signs of shock= signs of end-organ hypoperfusion Altered mental status (brain) Decreased urine output (kidney) Change in color/ temperature of extremities (skin) Abnormal liver function tests (liver) Ileus (gastrointestinal tract) Diagnosis of shock + tools for monitoring response to treatment Elevated lactate (global hypoperfusion) Ultrasound- evaluate cardiac function, evaluated IVC to assess volume status Minimally invasive cardiac monitoring (central line or arterial line)- CVP and SVV to assess volume status Invasive cardiac monitoring (pulmonary artery catheter)- cardiac output, ScVO2 (central venous oxygen saturation) Four types of shock Shock is typically categorized as hypovolemic, obstructive, cardiogenic or distributive. However, in order to link the specific category with the associated pathophysiology, I have described each state as it relates to maintaining cardiac output, as described above. Decreased preload: hypovolemic shock- low circulating blood volume→ decreased blood volume returning to the heart. Etiologies: bleeding, inadequate fluid replacement/ maintenance, high output from nasogastric tube or ostomy, insensible losses that aren't appropriately replaced (burn patients, large open wounds). Decreased preload: obstructive shock- disease process that impedes venous return to the heart (tamponade, tension pneumothorax, pulmonary embolism). Decreased contractility: cardiogenic shock- disturbance of the intrinsic function of the heart. Etiologies: heart failure, arrhythmias, valvular insufficiency, or decompensated valvular stenosis. Decreased afterload: distributive shock- dilated peripheral vasculature, sometimes known as vasoplegia. Etiologies: sepsis, anaphylaxis, neurogenic following spinal cord injury (NOTE- this is NOT the same as spinal shock), burns, trauma, pancreatitis. Neurogenic- hypotension with concurrent bradycardia. Vasoplegia is a term used to describe pathologically low systemic vascular resistance- this can be associated with post-cardiac bypass or any of the other causes mentioned here. Management of shock Treat underlying cause (see below). Restore adequate intravascular volume (aka preload). This is part of the initial treatment of hypovolemic shock, obstructive shock, and distributive shock. Fluids in the management of cardiogenic shock depend on the primary cardiac pathology. Treat hypotension/ decreased cardiac output that persists despite fluid resuscitation and treatment of the underlying cause. Septic shock- norepinephrine is the first line vasoactive medication. Monitor end-points of resuscitation (see above, Diagnosis of shock + tools for monitoring response to treatment ) Supportive care- nutrition, respiratory support, venous thromboembolism, etc. Specific Treatments Based on Etiology Hypovolemia from hemorrhage- transfusion, stop the bleeding Hypovolemia from fluid losses- replace fluid via enteral or intravenous route, as appropriate Sepsis- antibiotics, control source of infection (appendectomy, drain placement, etc). Tamponade- drainage of pericardial fluid (pericardiocentesis, pericardial window) Tension pneumothorax- release of tension physiology (needle decompression or finger thoracostomy) Cardiogenic- management of primary cardiac pathology, whether that entails treating acutely decompensated heart failure, resolving acute symptomatic arrhythmias, etc. Previous Next

6 Start with Why How Great Leaders Inspire Everyone to Take Action - Explains the importance of developing a shared philosophy for business, teams, and frankly, any mission. It relays a vital concept, but the text is unnecessarily repetitive- it could be significantly shorter while maintaining the message. - Regarding a business model- your "why" is your basic underlying philosophy, motivation, and guiding principle, your "how" is your process, and your "what" is your product. - You can convince customers to buy your newest product, but you have to re-create your marketing with each novel concept. Loyal customers buy your product because they believe in your philosophy. Think about Apple. They don't sell a product. Apple customers will purchase the next Apple product, not because of the particular design or nuanced update, but because they believe Apple's "why." - Ask an employee or a teammate- what do you do? Is their answer a description of their daily tasks? Or is it a message, a principle that guides their action? - If your company's "what" becomes obsolete, your company becomes outdated. If your company was created to copy written text manually, you would be unlikely to adapt to the new technology that successfully automates the process. If your company's "why" was focused on the value of literature and facilitating easy access to books for everyone, this will allow you to remain relevant regardless of how the world changes. Previous Next

3 Everybody Lies Big Data, New Data, and What the Internet Can Tell Us About Who We Really Are - The staggering amount of data available and the power to make predictions. - Internet search bars have entered society as a secret place to ask our most urgent/ personal/ embarrassing questions without risk of guilt or shame from others discovering intimate details about us. People lie on job interviews, online surveys, and almost anywhere they are at risk of being revealed, which introduces a significant bias in database queries. In contrast, there is no motivation to lie to the anonymous search bar. - Evaluating internet searches can reveal an infinite amount of information about society as a whole. Monitoring internet searches during presidential addresses, evaluating searches for unemployment offices, what to say on first dates- there is so much data that can be harnessed to understand society. Previous Next

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

How to be a Terrible First Date Dating, Pt 2 How to be a Terrible First Date Recently, I was set up on a blind date. He seemed like a normal mature guy via text. Polite, intelligent responses, etc. We agreed to meet at a local bakery. My first clue should have been the fact that he didn't have the fortitude to message me first. I don't do a great job of taking my own advice…I had told myself I wouldn't message first, that he would have to be the guy and reach out first. Oops. When I showed up, he was sitting outside. I sat down and he asked if I wanted to order something. He told me they have great food and good coffee, to which I replied that I don't drink coffee. And the date careened downhill from there. His response? Not drinking coffee is a red flag that a woman isn't a good partner. Goes along with not liking chocolate. He declared that if something else goes wrong later in the relationship, you can look back and say yeah they told me there was something wrong from the beginning. Then he went off on a tangent about how people who don't eat the same kind of foods won't be compatible in relationships. For example a vegetarian and a vegan. More specifically, a really douchey vegetarian or vegan. I didn't know people still used that word…actually, I didn't know that it was ever used out loud as an adjective by a guy. He continued with other crazy comparisons. Like Jewish people who don't eat pork. Or cannibals. Or carnivores. Told me a story about having a friend who ate dogs. Some context for the dog-eating conversation-- there was an adorable medium-sized fluffy black and white dog sitting about 3 feet away from us. He and his owner are clearly within earshot. He continued…."do you see that dog right there, she (his friend from Asia) would think it would be OK to eat a dog." I didn't know what to say to that. All I could say at that point was that I could never eat that dog, that I couldn't even kill a dog! His monologue about eating continued with an explanation of why humans are the superior beings on the planet. The bottom line was that the thing that makes us the superior being is the fact that we can eat any other animal. It's not our intelligence (dolphins are more intelligent), it's not our technology, we aren't faster or braver. But we can eat any animal. And somehow he related this to the use of smartphones- using a smartphone doesn't make you smart. A stupid person can use a smartphone but still eat any animal. He then delved further into the world of food and eating with a rant about McDonald's. You’ve heard of McDonald's, right? Are you too good to eat at McDonald's? Have you heard of Jim Gaffigan? He does a skit about McDonald's. You ever run into someone at a McDonalds’s and they ask what you’re doing there...you just pretend you’re meeting a hooker. Him: McDonald’s fries are the best thing. Me: not if they’re cold. Him: Well you have to eat them within 5 minutes. After those five minutes, they’re no longer food. Me: But they aren’t always warm when you get them. Him: Then that’s your fault. If you don’t check and you drive away, it’s on you. You can’t blame anyone else. Me: But who wants to be the person who holds up the line in the drive-thru? Him: You have to be coordinated, pay, and inspect the fries all at the same time. And if they’re cold, you hand them back and say these are cold I need new fries. And everyone in that line behind you will understand that. If you drive away and the fries are cold, it's your fault. I tried to change the subject by commenting on the restaurant. Told him there was a place I previously lived that had similar food, but the décor on the inside was quirky. It was awesome because it was open 24/7. His response…there weren't other places open 24/7? IHOP? I asserted that there were not many places….maybe Huddle House. He said he's never been to a Huddle House. I said it's like a worse version of Waffle House. He said, have you ever been to a Waffle House? It's like a truck stop bathroom with a kitchen. I told him, yes, and that Huddle House must be an East Coast thing. He told me they don't have it up north, so I said Ok, maybe it’s a North Carolina thing. Why does everything have to be a disagreement??? Finally, after complaining about not wanting to give up the table he picked, he agreed that we should go in and order food. When we were in line to order, the conversation took on a slightly different tone. He proceeds to lecture me on the fact that making requests or asking questions regarding food at a restaurant is a personality flaw. He also told me that you need to try everything at least twice. Without even knowing me, he was insulting people who make requests at a restaurant. He made some mention of bacon, and I said I don't care for bacon, and asked whether not liking bacon is as bad as not liking coffee or chocolate? He said that's not a big deal in Texas, maybe in North Carolina or Georgia it would be (the last two places I've lived…again, he knows nothing about me). When I asked why I have to try something else two more times when I already know what I like (or don't like), he said, what if you get to be 80 years old, and your tastes have changed? He told me, just go with the flow….he said if he orders beans and they give him rice instead, he'll just eat the rice. Me: But what if you really want beans. Him: Just go with it, order the beans next time. Some people eat dirt and mud. Me: Just because there are people who have to eat dirt doesn't mean we just have to eat whatever is given to us. Him: Don't ask a lot of questions to someone who barely has a high school education. So basically…he doesn't have a spine to ask for what he wants when he eats out. Probably translates into other areas of his life where he isn't able to stand up for himself…just a guess. So now that he's already insulting people who have preferences about food, I had to tell him about a recent outing with work colleagues. We went to an outdoor American food place, and I wanted a plain burger. The only thing they had on the menu was a burger with brisket on top. So I asked my friends if that meant brisket sauce or actual brisket meat. Immediately, my date tells me I asked too many questions. I tried to play along, acquiescing that barbeque is a big deal in Texas. But then, I said I don't eat that much food at one time and I didn't want more meat on my burger. He told me not to complain, and just eat half and give it to a homeless person. He told a story about giving food to a homeless person once in Austin…the homeless person asked if it was gluten-free, and then when he said I'm not sure, and the homeless person said, ok, never mind. So a weird humble brag, talking bad about a homeless person while simultaneously telling me he is a generous person. So again, it was my turn to tell a story about myself to see how he'd insult me some more. Me: I went to a restaurant that I really liked back home and I like the green beans there. I went there one time and they didn't have green beans. Him: You can be sad about that but don't be whiny about it. The restaurant was relatively crowded, kinda looked more like a Saturday morning than a Thursday morning. He did that awkward thing where he says rude things out loud so everyone around us can hear him being insulting. Him: Why are there so many people here? It's a Thursday morning. These people should be at their jobs. Me: You do realize we are here, right? The menu advertised a breakfast sandwich…which I guess I was going to order but had to make sure not to ask questions or tell them what I want. In an attempt to make a sarcastic joke, he asked about whether the sandwich was gluten-free. And if the chickens were free-range. I made a joke and asked if the chickens were treated well and whether they were mocked as children. When we got back outside, he complains about the fact that the table he had been sitting at was taken. Then he walks around and complains that the rest of the tables are equally bad. Not so easy going now, eh?? We sat outside, and as we were waiting for our food, several birds were dive-bombing me, to which I responded like a normal person and ducked. He proceeded to chastise me for not standing up to the bird and not asserting my dominance. He told me it didn't bode well for my offspring that I couldn't stand up to a bird. Stated I would just let my children be pecked to death by birds. Said I'd be helpless, and hopeless for the rest of my life. Literally used those words. Not even implied, straight out said I was hopeless and helpless. Somehow we got on the conversation of working, basically said he only does his job to make money. I asked him if he enjoyed it or enjoyed helping people, and he said being a neurologist was the best he could come up with using the advantages he was born with. He said there was nothing better he could do to make money, to which I replied that he was choosing to limit himself. While we waited, he decided to give me a lesson on animals and nature. On nature shows, the lion is shown as the majestic king of the jungle, but they hide the fact that lions will eat their young. This part was much funnier in person because his tone of voice and storyline was so ridiculous. Like he was actually offended or thought it was a conspiracy that this wasn't shown on TV. He also gave a long monologue about how big birds eat other birds. Like helpless penguins. Birds try to eat their eggs. Sometimes the big bird will be looking down and the other bird knows it's about to get eaten. Other times, the other bird doesn't even know. It'll just be sitting there one moment, and the next moment, hey I'm being eaten. When I turned and spoke to one of the many dive-bombing birds, he proceeded to correct me about calling a bird the wrong gender. He stated that men are the brighter of the bird species because they have to attract the female bird. Told me about watching a show that talked about males of different species trying to attract females. Like fish get the rocks all together to show the girl fish that they can make a nice place, and then the girl fish comes over, so the male fish does a dance, and then if they get turned down by a female, they clean up the rocks and try again. Birds try to make the best nest to impress female birds. Then he told me that males are brighter than females, across all species. To which I disagreed, stating that I don't think men are more colorful than women. He corrected me, saying that’s why men wear ties…. Again, I told him I'm pretty sure females are more colorful. And he said, yea, women just like to shop. He also told me he could tell which was a female bird because they were the ones that ate everything. Yes, he said those words. Out loud. To a woman he'd never met. Throughout the date, he spent 97% of the date not talking about me or asking about me. I did proceed to tell him about the time I was attacked by dogs. And I told him it changed my life. He responded by asking (at least twice) what I did to the dogs to make them attack me. Seriously. Told him my story about the dogs. After I finished, he asked if I was bleeding. I recounted my story of going to the ER…to which he responded with…nothing. No sympathy. No nothing. Told him the rabies shot is really painful because they had to put it in my ankle. He said they probably did it wrong and it was his goal in life to never need a rabies shot. I then told him about how it changed the nature of my deployment…again, no questions about me. I told him it was odd to talk about birds eating each other on a first date. And I didn't know how he planned to get second dates after that conversation. He said he had watched a documentary with his niece and it was something he learned. Then he asked me what I learned. And then just stopped talking and went back to eating. Didn't even eat half my breakfast…so uncomfortable, and I wondered if he would tease me for eating all my food. By the way, he also sat with his feet on the chair next to me, legs straight. Back when we were in line ordering breakfast, I asked if he was cold, cause he had long pants, a sweater, and a long black wool coat. He said, no, he wore that so he wasn't cold… During breakfast, he told me because I had my arms folded that I was either cold or standoffish. Said that a few times over and over to me…and he even mocked me by folding his arms tightly across his chest and scowling. I then laid my hands on the table in front of me. He continued to mock me. Later, he noticed goosebumps and told me I was cold. And then told me because I wasn't furry (or hairy, I don't remember), goosebumps mean I'm cold. Later on, we took a walk along the river walk. It was mostly painfully awkward silence. But a few times, he did that weird thing talking out loud saying awkward things that other people can hear… There was a lady behind us with a stroller. He said, "I feel like we're being followed". Later, a yappy little dog barked at us, to which he said "no kill, no kill". The only interesting thing he talked about was racing cars. He mostly mumbled quietly, but I encouraged him to speak up and finally learned something interesting about him. He races cars- most recently a Ferrari, and he just bought a Lotus that he is getting ready for racing. He also used to race a Honda Accord. Reminds me of an ex-boyfriend who drove a Ford Taurus, but was convinced that just because he could hit the gas pedal hard, he was a race car driver… And then, just like that, mercifully, the torture was over. He walked us back to his car, pointed it out, and then walked away. Didn't ask where I parked or offer to walk me back. Again, all the little things can be written off as one-offs. Ok, fine, he didn't walk me to my car. Fine, he put his feet on the chair next to me. Yadda yadda yadda. But all together within like an hour? Come Previous Next

10 Loonshots How to Nurture the Crazy Ideas That Win Wars, Cure Diseases, and Transform Industries - S type and P type loonshots. Innovators (creating loonshots) have to co-exist with the “businessmen”- you can’t just segregate different groups. The innovators need the company to make a profit so they can continue to take risks and make discoveries. And the business needs to nurture loonshots. - In case you were wondering how polarizing crystals were discovered. Or check out this article in Science magazine. - Bad decisions may occasionally result in good outcomes. But you need to analyze wins- you might not be so lucky next time. - Good decisions may result in bad outcomes. You made the best decision with the information at your disposal. In those same circumstances, you’d make that same decision. - How do crickets synchronize their chirps? - Percolation. A mathematical explanation for predicting events based on an inherent variable. - How do forest fires spread? Relevant variables- the distance between trees, humidity, wind. - How do pandemics start? How appropriate…depends on the proximity of individuals. - Phase transitions - Why do traffic jams occur? Just above a certain density of cars on the roads→ jam. - Emergence- innate characteristics of how a group functions based on the size (ie what patterns shift after the group reaches a size, although the precise size is variable for groups) While individuals remain puzzles, man in the aggregate becomes a mathematical certainty. Meaning- group dynamics are universal, regardless of the characteristics of the group members. Previous Next

< Back Machete Attack- Neck Trauma A 42-year-old male was brought from an outside hospital after sustaining deep, extensive penetrating wounds to the neck and forearms. When he arrived at the hospital, we noted defensive wounds on his forearms and a deep laceration across the anterior neck. The report from EMS was that the patient was assaulted with a machete. What are the management priorities? Prioritize primary and secondary survey and treat life-threatening injuries first. Don't be distracted with impressive wounds. Secure the airway and control active hemorrhage. He was initially seen at a small community hospital, where an endotracheal tube was placed through the tracheal wound, and then he was transferred to our facility. He was rapidly transported to the operating room for evaluation. What structures need to be evaluated? Vascular structures (carotid arteries, vertebral arteries, jugular veins) and upper airway/ digestive structures (esophagus, pharynx). The head and neck team was consulted, and they evaluated him in the operating room. The wound's extent was explored thoroughly. Surprisingly, there were no injuries to the vascular structures, and the injury was isolated to the airway. The endotracheal tube was exchanged for a formal tracheostomy and a stent was placed in the upper airway to prevent luminal narrowing while the repair healed. The wound was closed in layers. Management of Penetrating Neck Trauma WTA Algorithm Anatomy Zone 1 Clavicles/ sternum to cricoid Zone 2 Cricoid to angle of mandible Zone 3 Angle of the mandible to the skull base Hard signs- airway compromise, massive subcutaneous emphysema/air bubbling through the wound, expanding or pulsatile hematoma/ active bleeding, shock, neurologic deficit, hematemesis. Soft signs- hemoptysis, blood in the oropharynx, dyspnea, dysphagia, dysphonia, subcutaneous air, chest tube air leak, non-expanding hematoma, bruit/ thrill. Hard signs or hemodynamic instability→ ensure airway and transport to OR. No immediate operative indications? Depends on symptoms and the zone of injury. Zone 1 and 3- CTA to rule out vascular and aerodigestive injuries; assess the trajectory of injury. Injury→ repair. Concerning trajectory→ triple endoscopy (laryngoscopy, bronchoscopy, and esophagoscopy). Zone 2- symptomatic→ OR. Asymptomatic- serial exams or imaging. Operative approach The most common incision for exploration of neck wounds is along the anterior border of the sternocleidomastoid (SCM) muscle. Exposure of Zone 1 and 3 are more challenging and endovascular adjuncts are useful. Zone 1 may require median sternotomy with extension along the SCM. Zone 3 requires mobilization of the mandible. Zone 2 can be approached with a transverse cervical collar incision with SCM extension. - Tracheal injuries are repaired with monofilament absorbable suture. - Esophageal injury- debride unhealthy edges, ensure full exposure of mucosal defect, repair defect (single or double layer), buttress with SCM, or strap muscle. Place drain. - Combined tracheoesophageal injury- repair, and ensure repairs are isolated with interposition of a well-vascularized muscle flap. Previous Next

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 Taking a Trip Where to Stay- Alternatives to airbnb

A response to the Tweet about being offended by being referred to as anesthesia Don't Call me Anesthesia < Back A response to the Tweet about being offended by being referred to as anesthesia A response to the Twitter post about being offended by being referred to as anesthesia. "Dear world, Please do not call us “anesthesia”. We are not a medication. Acceptable alternatives would be: Are you the anesthesiologist? Are you part of the anesthesia team? What is your role? I’m Dr. X and you are? Thank you for your attention to this PSA." Yes, I often refer to the "head of the bed" (the anesthesia team) as "anesthesia" (or "head of the bed"). There is absolutely no disrespect associated with this. We aren’t actually under the impression that our colleagues in other specialties don’t have names. I don't walk down the hall and wave while saying "hey cardiology how are you" or "hey GI any good scopes recently". But when it’s a chaotic/ urgent situation (responding to a code, crash laparotomy, busy trauma bay), don't get offended that your name isn't at the tip of my tongue. When you walk in and I say "anesthesia is here" or ask "are you anesthesia", everyone in the room automatically understands the change in the dynamic. We all know that someone skilled in airway management and sedation has arrived. Trust me, it's not about reducing you to a bottle of propofol. We don't need your name…we need your skillset. When there is a time for conversation, I will ask your name if I don't know you. Or I'll say, sorry, I know we've met, remind me of your name. As for being in the OR. There is only one team that doesn't take breaks or have teammates that "sub in" in the OR, and that’s the surgical team. Nurses, scrub techs and anesthesia providers all have personnel that can relieve them during the game. So when I look back toward my scrub tech and see a different face, I will ask their name. But when you're on the other side of the blood-brain barrier (also known as the sterile blue drapes), I can't see your face. And again, you might change multiple times throughout the case, so don't expect me to keep tabs on who is there when I'm focused on the task at hand. That’s an unnecessary cognitive load. I have modified my practice this week. In the last step of every preoperative timeout, just before incision, everyone introduces themselves and states their role. It humanizes everyone and serves to remind us that we are on the same team. And breaks up the formality and rote practice that we fall into. Outside the OR, I still don't have the ego to be offended by being referred to as my specialty. You can call me “trauma” or “surgery” whenever you want. I’d be giddy if every time I walked into a room, people stopped and declared “trauma is here”. And every person in that room either knows me (regardless of whether they know or forgot or never knew my name) or doesn't know me. But my name is irrelevant- the patient is the priority. Previous Next