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

5 Critical Care References ICU Rounds A-F Bundle .pdf Download PDF • 33KB Pharmacology Med Doses .pdf Download PDF • 56KB Neurologic RASS .pdf Download PDF • 281KB CAM-ICU .pdf Download PDF • 127KB CPOT .pdf Download PDF • 76KB EtOH Withdrawal .pdf Download PDF • 1.02MB Cardiac Arrhythmias .pdf Download PDF • 1.55MB Pulmonary Cuff Leak .pdf Download PDF • 15KB Fluids, Electrolytes and Nutrition Fluids .pdf Download PDF • 29KB Na and pH .pdf Download PDF • 53KB Endocrine and Nutrition Types of Insulin .pdf Download PDF • 85KB TPN .pdf Download PDF • 221KB Steroids .pdf Download PDF • 36KB Hematology Anticoag .pdf Download PDF • 44KB Anticoag Reversal .pdf Download PDF • 334KB Organ Donation Hormone Therapy .pdf Download PDF • 13KB

Caring for soldiers in the deployed environment Austere Damage Control Surgery < Back Caring for soldiers in the deployed environment “Our general attitude around here is that we want to play par surgery. Par is a live patient.” Several years ago, when I was preparing to apply for trauma fellowship, someone called me a meatball surgeon. I thought it was a lame nickname that meant our job was mindlessly easy. For the first time ever, I recently Googled meatball surgery. The term "meatball surgery" was used to describe the damage control interventions performed in MASH. Yes, I am proud to say I am a meatball surgeon for our soldiers. Telling me I save lives is a compliment…not an insult. Meatball Surgery Military surgeons are frequently deployed to far forward environments to perform damage control surgery- stopping bleeding, stopping gross spillage of bowel contents, stenting vascular injuries, etc. This allows the patient to be evacuated to the next level of care. The goal is NOT definitive repair of injuries. All general surgeons deploy in this role- so maintaining trauma operative skills and the skill of "thinking like a trauma surgeon" is crucial. This is being increasingly provided between deployments with skills labs and military civilian partnerships. There is still a significant gap between recommended case volume and actual case volume. Recently, the suggestion to train non-surgeons to do “just a bit of damage control surgery" in the deployed environment has been proposed in several forums, including on social media. Short version: “You can’t convince me that pelvic packing, laparotomy, vascular control, thoracotomies are difficult.” Why is this a problem? As mentioned, its hard enough to train our general surgeons well-trained to perform in this environment. It would take significant changes in our current training rhythm to get Pas and non-surgeons adequately proficient to provide this skillset. It is NOT easy being a trauma surgeon. A lot of surgery residents are familiar with the oft repeated quote, "you can teach a monkey to operate". It's not meant to insult trainees and compare them to monkeys. It's meant to explain that the difficult skill of being a surgeon is the judgment to decide who needs surgery, what surgery is needed and how to anticipate the next step. There are many algorithms in surgery. They are excellent guides to optimal patient care. But they all have the same caveat (although some might not state it as explicitly)- they are not to be used in isolation, but instead in the setting of sound clinical judgment. To gain this expertise, surgeons endure 4 years of undergraduate education, 4 years in medical school, 5-7 years of surgical residency, and 1-2 years of fellowship. And even after I spent all this time training, I’m still not done learning this art. If you say these are "not difficult” procedures, I encourage you to complete a general surgery followed by a trauma fellowship. The military actually does need more trained trauma surgeons. But no, I’m not interested in training a non-surgeon to do “just a little bit” of trauma surgery. I can't imagine any trauma surgeon who would be willing to teach a watered down version of our skill to a non-surgeon and sign off that they’re qualified to care for our soldiers. Please don't insult our expertise. I would never presume to be an expert in another persons specialty. This would be similar to suggesting that I can be easily trained to be special forces. Anyone can be taught to shoot a weapon, evade the enemy, decide the best tactical approach, etc. You may say that’s an exaggeration. But it’s the absolute truth. A field surgeon is NOT a surgeon. A brigade surgeon is NOT a surgeon. A flight surgeon is NOT a surgeon. A division surgeon is NOT a surgeon. A battalion surgeon is NOT a surgeon. The Surgeon General is NOT a surgeon. Previous Next

9 Black Swan The Impact of the Highly Improbable - Silent evidence- you can’t determine causality just by studying the successes. You don’t know the traits of the failures- they could be the same as the successes. Failed writers aren't necessarily bad writers. - The absence of evidence (no evidence of disease) doesn’t mean evidence of absence. - Recognize the unknown unknowns. - Mediocristan (finite limits- weight, height, etc.). Extremistan (boundless- income, book sales, retweets). - The turkey, which is fed every day until thanksgiving, doesn't realize he's getting closer to death. - When a black swan occurs, people rationalize in hindsight and state that it was inevitable. - Series of events preceding a particular situation doesn’t imply causality. We give narratives to make sense of events. - Humans are the victims of an asymmetry in the perception of random events. We attribute our successes to our skills, and our failures to external circumstances outside our control, mainly, to randomness. There is something in us designed to protect our self-esteem. - The law of iterative expectations. If I expect to expect something at some date in the future, I already expect that something now. Stone Age historical thinker is called to write about the events of the era. If he predicts the wheel, then the wheel already exists as a concept. - Different conclusions can be drawn from the same data. Every day you’re alive...you could be closer to death or immortality. Previous Next

< Back Ultrasound: Cardiac Exam Purpose: identify possible causes of hemodynamic instability, respiratory distress, assessment of volume status. Probe The phased array can be used for the entire exam. The curvilinear can also be used for the subxiphoid and IVC views. Views There are 4 basic views, including the parasternal long axis, parasternal short axis, the apical four chamber and the subcostal view. Additionally, the inferior vena cava can be visualized. Cardiac ultrasound is more challenging to learn than most other ultrasound studies, because probe usage (position, angle, rotation, translation, etc) have drastic impact on visualization. It’s necessary to understand what is shown in each view, so take time reviewing these so you can have a better appreciation for what you are seeing when you perform a study on a real patient. One recommendation, if it is difficult to visualize the heart, moving the patient into the lateral decubitus with their left side down can significantly improve visualization as the heart is closer to the chest wall in this position. For video and pictorial explanations of the views, please refer to these sites. Basic Cardiac Views, #1 Basic Cardiac Views, #2 Findings Gross abnormalities- decreased ventricular function, arrhythmias Profound hypovolemia Small hyperdynamic left ventricle with end-systolic collapse Inferior vena cava- assess volume status, either static measurement of diameter or calculation of collapsibility (>50% correlates with volume responsiveness). Respiratory variation (collapsibility/distensibility index). Takotsubo cardiomyopathy Akinesia of the apical and mid-ventricular segment, hypercontractile basal segments. Apical sparing (dilated). Acute cor pulmonale Respiratory disorder→ pulmonary hypertension→ right heart failure. Dilated right heart. Cardiac tamponade Effusion with end-diastolic collapse of the right atrium, effusion in front of the aorta Pulmonary embolism Free-floating thrombus in the right ventricle or pulmonary artery; right ventricular dilation/ systolic dysfunction; septal bowing into the left ventricle; dilated IVC without inspiratory collapse. Most sensitive/ specific indirect sign- right ventricular apical sparing (McConnell's sign). References Guidelines for Performing a Comprehensive Transthoracic Echocardiographic Examination in Adults: Recommendations from the American Society of Echocardiography Previous Next

Meal Prep: Eating with Intention < Back Kitchen Hacks #1 Meal Prep: Eating with Intention Want to stop eating cereal or takeout for dinner? Want healthy food options in the house? Whether you have a big family or you’re cooking for one, you CAN be more purposeful about your eating habits. Cooking healthy delicious meals while maintaining variety at meal time and keeping your kitchen stocked so that you’re able to cook without having to make multiple trips to the store doesn’t have to be an intimidating endeavor. Let’s walk through the key components of a successful cooking plan. * Create a collection of recipes . Some people might not routinely rely on recipes when cooking- if that’s you, feel free to skip over this. However, for the rest of us, recipes serve as the basis for meal prep. Your collection can be as simple or complex as you want. Recipe cards in a box or book, pages ripped out of magazines, cookbooks with bookmarks, links to recipes online, a basic phone app or even just a simple word document- whatever works best for you. After you decide on how to collect your recipes, the next step is making recipes easy to find. ** Organizing- Start with a few broad categories, such as breakfast, side dishes, sandwiches, main course and dessert. Once you are familiar with how you use your recipe collection, feel free to create more specific categories. For example, my categories include apps and side (sub-category: vegetables), bread (sub-category: breadmaker), breakfast, dessert (sub-categories: brownies and bars, cakes, candy, cookies, cupcakes, ice cream and pies), dinner (sub-categories: chicken, crockpot and fish), dips and sauces, new recipes, pasta, pizza, salad and finally, sandwiches and burgers. * Create a collection of meals. You probably have a few combinations that you routinely prepare and serve. For example, meatloaf, mashed potatoes, and green beans. Not every food needs a recipe, and you might even do some meals from memory. But creating a list of meals can help remind you of dishes you haven't had in a while and gives you more options to choose from when you’re in a rut. * Create a list of items in your pantry (and fridge/ freezer)- specifying quantity is important. You don’t have to include every item, but keeping track of commonly used items can help avoid situations such as three extra bags of white sugar or running out of key spices. * Create a meal schedule. Just like everything else, this can be as simple or detailed as you would like. Whether you do a weekly meal prep session or plan meals a day or two at a time, a schedule can help you remember to set aside or purchase the necessary ingredients ahead of time. A schedule can also help when projecting leftovers- like what meals are a good setup for packing a lunch the next day. * Create a grocery list. At a minimum, you should jot down what you need before leaving the house. But there are several ways to optimize your preparation for the grocery store. Making the list at home is key, because you can check what you have in your pantry/ fridge. ** Develop a list of commonly purchased items - this will make it easier to add things to your list before you head to the store. ** Keep a list near the refrigerator or pantry- this can be a simple notepad, a white board or whatever else suits you. When you are in the kitchen and notice that you are running low on something you normally have on hand, just jot it down on the list. Then on shopping day, it’s easy to keep track of staple items. ** Using your meal schedule/ recipes, you can gather the ingredients that aren’t in your collection of staple items. This is often fresh fruit/ produce or dairy/ meats. ** If you find yourself at the grocery store on the way home from work (or anytime you haven’t had a chance to make a list), you can pull together a meal by selecting from your recipes or meals and then sorting through your pantry list to determine what ingredients are missing. * I recommend downloading the Paprika application (iTunes application , $4.99). It is an all-purpose tool for collecting/ sorting recipes, creating menus, keeping track of ingredients in your pantry/ refrigerator/ freezer and making a grocery list. You can add recipes from almost any website and can also manually add personal recipes (and even add a picture of your own creations!). You can create a menu schedule and grocery list directly from recipes. Keeping everything in one place avoids the need to refer to different resources (recipe book, list on the refrigerator, electronic version of a pantry list). * Here are two of my favorite websites for recipes. ** Cooking Light Free access to countless delicious healthy recipes! ** How Sweet Eats Started following this years ago when I stumbled on some of the recipes on Pinterest. Love the name- we are both fans of James Taylor! Previous Next

< Back Abdominal Pain- Mesenteric Ischemia A 65-year-old male with 1 week of progressive abdominal pain presented to a small hospital. His medical history is significant for a myelofibrosis with chronic portal vein thrombosis. He underwent CT scan and was urgently transferred to the surgical ICU at the nearby tertiary hospital. CT abdomen and pelvis (coronal) https://video.wixstatic.com/video/3b6ff6_3a044f13731447f68a338b2b814e0d65/480p/mp4/file.mp4 CT abdomen and pelvis (axial) https://video.wixstatic.com/video/3b6ff6_102334b9eba6428f8c132cdcc0aa175e/360p/mp4/file.mp4 The abdomen pelvis CT showed chronic portal vein thrombosis with cavernous transformation as well as distal SMV thrombosis with inflammatory changes of the distal small bowel. There is a moderate amount of intra-abdominal fluid, including around the spleen and liver as well as in the pelvis. There is thickening of the small bowel wall as well as stranding and edema in the mesentery. There was also evidence of a splenorenal shunt. Representative slice from CT, axial Representative slice from CT, axial- labels Representative slice from CT, axial Representative slice from CT, axial- labels Differential diagnosis? Splenic injury secondary to splenomegaly (minor trauma can lead to splenic injury in the setting of splenomegaly). Bowel ischemia. Hollow viscus perforation. On arrival to the ICU, his abdominal exam revealed diffuse rebound tenderness. He became disoriented during our interview. Concurrent with our evaluation, the images with reviewed with radiology who reported that the fluid was not consistent with hemoperitoneum from a splenic injury. Based on our concern for bowel ischemia, he was taken to the operating room for abdominal exploration. He was noted to have a significant length of ischemic and necrotic bowel. This was resected and his bowel was left in discontinuity. He was returned to the ICU with an open abdomen and plan for second look laparotomy within 24 hours. Evaluation and Management of Acute Mesenteric Ischemia Causes Arterial Embolism- from the left atria (atrial fibrillation), left ventricle (decreased function following cardiac ischemia) or heart valves. Arterial Thrombosis- progression of underlying atherosclerotic disease leading to critical stenosis at the takeoff of the celiac or SMA from the aorta. Venous Thrombosis- hypercoagulable states, acute inflammatory process around the SMV (pancreatitis), post-operative following splenectomy or bariatric surgery. Non-occlusive mesenteria ischemia (NOMI)- low-flow through the SMA with vasoconstriction. Often having underying illness or cardiac failure, which is exacerbated by vasoconstrictive medications and hypovolemia. Presentation Severe abdominal pain, "pain out of proportion to exam" (report severe pain but abdominal exam doesn't elicit tenderness). Arterial thrombosis may be acute on chronic, if there is underlying chronic mesenteric ischemia. Diagnosis Etiology can be suspected based on symptoms and medical/ surgical history. Sudden onset is suggestive of arterial embolism. Known hypercoagulable state is suggestive of venous thrombosis. Chronic abdominal symptoms including pain with eating (food fear) and weight loss are suggestive of arterial thrombosis. Imaging Plain films may be non-specific, but may show free air or portal venous gas later in the course. Angiography Arterial thrombosis- often seen right at the takeoff of the celiac or SMA from the aorta. Arterial embolism- typically an occlusion of the celiac or SMA at a branch (versus right at the takeoff). Treatment Volume resuscitation, antibiotics Anticoagulation Surgery consultation for assessment of bowel viability and treatment of vessel occlusion Previous Next

< Back What happens during Surgical ICU (SICU) Rounds? This does NOT reflect the practice pattern of every SICU. All the components must be addressed, but there are many variations on how they are incorporated into the daily routine. Flash Rounds A multi-disciplinary process that includes the charge nurse, respiratory therapist, clinical nutritionist, physical therapists/ occupational therapists, clinical case manager, and a senior member of the team (attending, fellow, APP). Focused on ensuring that each patient has daily goals and a plan from each of the team members, ensuring that key issues are addressed early instead of waiting until after rounds (nutrition, plans for ventilator weaning, disposition planning, etc.). Working Rounds A multi-professional process that includes the bedside nurse, "learners" (broad term to include students, residents, advanced practice provider (APP) fellows), as well as the APPs (nurse practitioners (NP) and physicians assistants (PA)) and a clinical pharmacist. The team is led by the attending physician or critical care fellow. Engagement and communication by all team members are encouraged. After reviewing overnight events, a system-based approach is used to methodically evaluate the patient's current clinical status and then develop a management plan. 1. Systems-Based Rounds- presented by resident or APP - Neurologic- assessment of mental status, including the Glasgow Coma Scale (GCS), Richmond Agitation-Sedation Scale (RASS), etc. Current sedation and analgesia regimen. Review relevant radiologic imaging. - Cardiovascular- relevant vital signs and hemodynamic monitoring parameters, including trends and ranges. Review current cardioactive medication. - Pulmonary- current ventilator settings, relevant laboratory values (arterial blood gas), relevant radiologic imaging (chest radiograph). - Gastrointestinal- physical exam. Assess nutritional status (tolerating enteral nutrition, contraindication for enteral feeds, plan for parenteral nutrition). Review relevant radiologic imaging (abdominal radiograph). - Genitourinary/ Renal- review intake/ output (I/Os). The total volume of fluid intake (intravenous fluids, nutrition, blood, antibiotics, etc.) and fluid output (urine, stool, drains, etc.). Relevant laboratory values (basic metabolic panel). - Endocrine- review glycemic control. - Hematology- assessment of coagulation status or abnormal blood counts (hemoglobin, platelets). - Infectious Disease- physical exam- fever and evaluation of all possible infection sources (catheters, wounds, respiratory secretions). Review relevant laboratory values (white blood cell count, culture results), review current antibiotic therapy. - Prophylaxis- review needs for venous thromboembolism and stress ulcer prophylaxis. 2. A-F Bundle presentation by bedside nurse [SCCM ICU Liberation Bundle] - Assess, prevent, and manage pain - Breathing (Spontaneous awakening and breathing trials) - Choice of analgesia and sedation - Delirium assessment, prevention, and management - Early mobility and exercise - Family engagement 3. Develop a management plan based on comprehensive patient assessment. Previous Next

< 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

Practical Tips on Having a Difficult Discussion How Do I Do It? < Back Practical Tips on Having a Difficult Discussion This blog is complementary to the previous blog about becoming more comfortable with uncomfortable conversations. After many difficult discussions with families during my critical care fellowship, I finally became comfortable with uncomfortable conversations. It's impossible to develop a script to use for every conversation, but here are some of the techniques I've adopted over the years. Sit down in a private room, have tissues if appropriate. Make sure your phone/ pager won't interrupt the conversation. Have someone else with you. It’s always good to bring the patient's nurse, and there is often spiritual support staff (ie chaplains) who can accompany you and provide support for the family. Introduce yourself, and ask who everyone in the room is, specifically how they're related to the patient. "Nice to meet you, I'm really sorry it's under these circumstances." If it's your first conversation with the family, it's important to establish a foundation to build on (or establish the absence of a foundation). You can ask "what do you know so far" or "what's your current understanding of the situation"? This also allows them to express their current questions/ concerns. Judge their level of comprehension and adjust as needed. This does NOT mean being patronizing or imposing stereotypes. Pay attention to facial expressions and listen to their questions/ responses. It's easy to fall back into speaking medical jargon- you need to deliberately focus on using easily understandable words. Words that we use every day are meaningless to most people who aren't in the medical field. Keep the conversation brief and take frequent pauses. They don't hear everything you say, and they'll hear even less if you talk non-stop. Allow them time to process what you’ve shared, and allow them to ask any questions they have. Acknowledge that it’s common to be overwhelmed by the discussion. You can validate them by offering "I know I just told you a lot of information" or "I know this can all be overwhelming". It’s also helpful to say, “I’m sure you will think of other questions, please write them down so we can discuss them later” Encourage them to discuss things amongst themselves and provide them a quiet private place to regroup after the meeting. It’s also helpful to say, “I’m sure you will think of other questions, please write them down so we can discuss them later.” This validates their feeling and reassures them that they don't have to worry about remembering every detail. Specific difficult topics - Death and dying. Acknowledge that what they are feeling is normal- regardless of what they feel, it's normal. Denial, angry, scared, guilty, confused, conflicted, exhausted, numb. - When they are wrestling with the decision about transitioning to comfort care (colloquially known as "withdrawal of care", or crassly, "pulling the plug") and they've verbalized that they know it's what their family member would want, acknowledge how difficult that decision can be but also reaffirm that they are doing the kindest thing by honoring their family members wishes. For other helpful tips, check out "Sunburn". "For patients who are alive, concentrate on the ‘big picture’ and avoid the inclination to catalog every injury during this initial encounter. The primary concern in these settings often consists of survival, brain damage, paralyzation and other major morbidities. Again, an overabundance of information can be overwhelming." Velez D et al. SUNBURN: a protocol for delivering bad news in trauma and acute care surgery. Trauma Surg Acute Care Open. 2022 Feb 9;7(1):e000851. Previous Next

Advanced Practice Nurses to begin coming to Code Blues and supervising residents Code Blue: Who's in Charge? < Back Advanced Practice Nurses to begin coming to Code Blues and supervising residents I recently came across this article on Twitter and wrote my reply as soon as I read it. But as I was preparing to post this, I did a little more background research on the article. Let's start with the source- the website is called "MidlevelWTF ". The tagline is- "Exposing midlevel incompetence in the fight to ensure patient safety and preserve physician-led, physician-supervised medicine." The author's user name/ Twitter handle is MidlevelWTF; motto: "an actual doctor, with an actual MD." In light of this, the tone of the article makes much more sense. I'm disgusted to discover that a physician has dedicated their time/ energy to specifically target and defame APPs. Reply I disagree with a policy that formally designates a nurse practitioner to supervise any resident who runs a code. It's not appropriate to assign anyone else the authority to unilaterally overrule the decisions of the code leader. Codes need 1 leader- this is typically not the most junior person in the room, but someone in the middle or upper level of their training- a midlevel or senior resident. This doesn’t mean leaders can’t get recommendations from others. The more senior personnel in the room are welcome to provide advice- if there is egregious incompetence, which I would guess is the exception far more than the rule, someone, such as an attending or fellow or senior resident, can take over the role as leader. Working with the premise that the leader is competent, correcting a mistaken dose, helping develop a differential and general troubleshooting are all in the patient's best interest. These are also integral to closed-loop communication, and shouldn't be considered undermining or met with resistance. Team members should be able to speak up freely without having to worry about being yelled at for correcting another provider who is potentially more senior. The problem with this policy lies in the disruption of the team dynamics- adding another layer of "leadership" by formally assigning someone to have authority over the team leader creates confusion. If there is a contradiction, does the team listen to the leader or the "assigned" supervisor, who could reasonably have less experience than the resident? I've gladly welcomed advice from those with more experience than me during a difficult situation, and I trust them to speak up if they see something amiss. I trust all the non-physicians who care for our patients in my absence, and I trust them to call me if there is any concern; I hope they will feel empowered to do this in a code situation as well. So I support the author's general stance that the policy is inappropriate. However...I take great offense at this article. Implying that nurse practitioners (NPs) are minimally qualified and poorly educated is insulting and severely erroneous. Worst of all, the writer implied that a midlevel might decide to call it quits on a code “because they didn't feel like doing it anymore.” Absolutely inflammatory. Implying that any healthcare professional would be lazy or bored and just give up is preposterous. I have worked with many APPs (advanced practice providers), which includes NPs and PAs (physicians assistants) in the ER, on the inpatient wards, in the operating room, in the ICU, and in clinic. I have found them to be phenomenal teammates, motivated and eager to continually learn about how to best care for patients. Yes, some are less competent than others. But this is equally true of all healthcare professionals. I would gladly have a competent NP run a code if they were at the bedside at felt comfortable/ empowered to do so. While I would never designate a non-physician to oversee a resident running a code, I would similarly never expect a resident to take over the role of team leader from a competent NP or PA. As a fellow, during my time in the ICU, I would gladly let either an APP or a resident run the code, depending on availability and comfort level. I would be readily available and provide input when needed such as when the decision-making process extends past the algorithm of ACLS and into specific patient scenarios. In addition, if the patient needed an emergent/ urgent procedure, I was free to perform or assist while those procedures were being performed, as the NP/PA or resident continued to manage the overall code situation (meds, compressions, US to examine for cardiac activity, calling for MTP, etc). So I disagree with the policy, but I am deeply disappointed in the way the author chose to make petty accusations to undermine APPs and justify their disagreement with the policy. It's disappointing that a professional would stoop low enough to attack the character of our teammates. Previous Next