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< Back Ultrasound: Thoracic Exam Purpose: evaluate for etiology of respiratory failure- pleural fluid collections, pneumothorax, infiltrate, pulmonary edema. Probe Linear for visualization of superficial structures- for example, the pleural interface to evaluate for lung sliding Curvilinear or phased array for the remainder of the lung Findings A and B Lines A-lines- *normal finding*. Hyperechoic arcs parallel to the pleural line. These are seen at intervals that are the same as the interval from the skin to the pleural line. Absence of A lines= change in attenuation coefficient of the lung (edema, consolidation). B-lines- vertical hyperechoic lines, caused by fluid-filled intra-lobular or interlobular septa touching the visceral pleural surface. Examples: cardiogenic pulm edema, ALI, ARDS, pneumonia, ILD or pulm fibrosis, pulm contusion. Comet tail artifact- *normal finding*. Arise from the pleural line and only extend 2-4 cm deep before fading (unlike B lines). They mean that the pleura are in contact. Pleural sliding Shimmering of the hyperechoic pleura→ pleura are in contact. No sliding→ concerning for PTX. There are clinical conditions other than PTX that result in a lack of lung sliding: Effusion, inflammatory adhesions, (pneumonia, ALI), pleurodesis, interstitial or fibrotic lung disease, pleural disease, apnea, severe hyperinflation (asthma, COPD), artifact (subQ air). M mode- sliding→ seashore. No sliding→ barcode. Lung pulse - cardiac motion causes the two pleura to slide Lung point - the junction between the edge of the pneumothorax and the normal lung, where the pleural surfaces meet. One side is sliding and the other side isn’t. Consolidation Air bronchograms- air in small aerated patches of the consolidated lung, or the small bronchi. Dynamic- bubbles move in and out with each breath- no complete bronchial obstruction, more likely true consolidation vs atelectasis. Pneumonia- advanced consolidation (air is completely replaced with fluid)→ lung appear to have a liver-like echogenicity (hepatization) Diaphragm - evaluate diaphragm contraction and thickness. Effusions Spine sign- the presence of a large effusion allowing visualization of the spine. Normally the air in the lung prevents visualization of the spine above the level of the diaphragm, but sound waves can pass through the fluid. Plankton sign- floating debris in an effusion that swirl with pulm or cardiac motion→ blood/ fibrin suggestive of HTX/ exudate Jellyfish sign- consolidated or compressed lung is floating in the pleural fluid. Common Pathologies with their associated ultrasound findings PTX- no lung sliding, M-mode barcode sign, lung point sign, A-lines from intact parietal pleura Pulmonary edema- B lines, normal lung sliding, +/- effusions ARDS- B lines, normal lung sliding References Lung Ultrasound Made Easy: Step-By-Step Guide Lee FC. Lung ultrasound-a primary survey of the acutely dyspneic patient. J Intensive Care. 2016 Aug 31;4(1):57. Previous Next

< Back Chunky Tomato Bisque Ingredients 6 celery ribs, chopped 1 large onion, chopped 1 medium sweet red pepper, chopped 1/4 cup butter, cubed 3 cans (14.5 oz each) diced tomatoes, undrained 1 tablespoon tomato paste 3/4 cup loosely packed basil leaves, coarsely chopped 3 teaspoons sugar 2 teaspoons salt 1/2 teaspoon pepper 1-1/2 cups heavy whipping cream Instructions 1. In a large saucepan, sauté the celery, onion and red pepper in butter for 5-6 minutes or until tender. Add tomatoes and tomato paste. Bring to a boil. Reduce heat; cover and simmer for 40 minutes. 2. Remove from the heat. Stir in the basil, sugar, salt and pepper; cool slightly. 3. Transfer half of the soup mixture to a blender. While processing, gradually add cream; process until pureed. Return to the pan; heat through (do not boil). The vegetables sautéing Previous After blending Dinner is served! Next

< Back Electrolytes...pending Electrolyte Management Previous Next

< Back Stabbed in the Right Thigh A 42-year-old male is brought to the Emergency Department as a Level 1 trauma activation for a stab wound to the right thigh. He was hypotensive before arrival, with SBP in the 70s-80s. Estimated blood loss of 500 mL on the scene. On arrival, the patient is awake and argumentative. His blood pressure is 90 systolic. On a rapid secondary survey, there is no evidence of any other wounds. There is a tourniquet in place to right upper thigh. When the tourniquet is released, there is arterial bleeding from the wound and there is no palpable distal pulse. What do you need to do before leaving the trauma bay? Replace tourniquet. Call OR to have vascular instrument set available, as well as massive transfusion, cell saver, etc. Type and cross for blood transfusion. After ensuring a type and cross, we proceeded to the operating room. How do you want to prep and drape the patient? Any instructions for anesthesia? Wide prep and drape to ensure adequate access for proximal and distal control- this includes prepping the lower abdomen for possible iliac exposure. Also, need to prep contralateral lower extremity for potential saphenous vein harvest. Ultrasound localization of the saphenous prior to prepping can allow identification of the larger vein. Anesthesia will need to monitor hemodynamics and volume status and be prepared for volume resuscitation with blood. In addition, they will have to be vigilant for the repercussion syndrome, the metabolic disturbance following the re-establishment of arterial flow (washout of toxins following ischemia). We placed a pneumatic tourniquet on the patient's upper thigh. We prepped and draped from the umbilicus to the knees, and also prepped and draped the contralateral thigh to have access in case a saphenous vein harvest was required for repair. We made an incision directly over the wound and dissected down to the artery. There was a single wound in the anterior surface of the distal superficial femoral artery. Proximal and distal control was obtained after circumferentially dissecting and placing vessel loops. The artery was divided and spatulated. It was repaired with an end to end tension-free anastomosis. Following arterial repair, we performed a lower extremity fasciotomy. Management of Penetrating Arterial Trauma WTA Algorithm Diagnostic Workup Hard signs- pulsatile bleeding, thrill, bruit, expanding hematoma, pulse deficit, cold pale limb. These patients require operative intervention. A few exceptions can benefit from preoperative imaging to document the presence and location of associated arterial injuries: wounds in the thoracic inlet, shotgun wounds in the extremities, and segmental fractures or fractures at different levels of an extremity. Soft signs- history of pulsatile bleeding, wound near an artery, non-expanding hematoma, neuro deficit, weak pulse, proximity injury. These patients need further workup to evaluate for the presence of arterial injury. An ankle-brachial index should be performed, and if ≤0.9, CT angiography is indicated. If ABI >0.9- no further w/u needed. ABI <0.9- CTA. Principles of arterial repair 1. Plan incision to facilitate proximal and distal control. 2. Ensure adequate back bleeding. Fogarty to remove distal thrombus. 3. Tension-free anastomosis. Adequate lumen. Clean margins. Don't create more damage to the vessel. 3. Consider risk/ benefit of heparinization. Systemic dose: 70-100 units/kg IV. Regional dose: 50U/ml x50 mL. 4. Completion angiogram to document repair. There are various techniques for creating an anastomosis, but the basic principles must be maintained. Recently, I was taught a useful technique [Dr. Feliciano, AAST 2020 Virtual Conference] that prevents tension at one point along the anastomosis. A parachute technique, starting with loosely approximated sutures on the back wall, followed by parachuting the two ends close to continue the suture on the anterior surface of the artery. Indications for fasciotomy include prolonged limb ischemia (>6 hours), combined arterial and venous injuries. 1. Feliciano DV. Evaluation and Management of Peripheral Vascular Injury. Part 1. Western Trauma Association/Critical Decisions in Trauma. J Trauma. 2011;70(6):1551-1555. 2. Feliciano DV. Pitfalls in the management of peripheral vascular injuries . Trauma Surg Acute Care Open. 2017;2:1–8. Parachute Technique [Feliciano] WTA Algorithm for Peripheral Vascular Trauma Previous Next

Ratios < Back Kitchen Hacks #5 Ratios Cooking with Ratios Bread 5:3 flour to water- for example, 300g flour and 180g water. With this ratio in your arsenal, the world of bread is at your fingertips. You can explore different flours, hydrations, and additions like seeds and nuts from here. Salt: Around 2% of the flour weight (e.g. 6g salt for 300g flour) Yeast: Around 1% of the flour weight (e.g. 3g yeast for 300g flour) Muffin/Quick Breads 2:2:1:1 flour:liquid:eggs:fat Baker Move: Baking times and temps can vary based on something as simple as the humidity in the air. Pros test the doneness of muffins, quick breads and cakes by simply inserting a toothpick. If it comes out clean, they are ready to cool. Biscuit 3:2:1 flour:liquid:fat Baker Move: Pros always scoop flour, sugar or other dry ingredient into a measuring cup, then use the back of a knife or other straight edge to level it off. Vinaigrette 3:1 oil to vinegar. Add herbs, garlic, or mustard to elevate your dressing Cookies 3:2:1 flour:butter:sugar Other ingredients like eggs, baking powder, and flavourings can be added, but the core 3:2:1 ratio for the main dry, fat, and sweet components is the foundation. Baker Move: Using a dough scoop (like a small ice cream scoop) to portion equal-size cookies adds a professional touch to your finished cookie plate. Pound Cake 1:1:1:1 flour: egg: fat (unsalted butter): sugar Baker Move: Pull your butter and eggs out of the fridge a couple of hours before you're ready to bake. Room-temperature butter is better for creaming, and you'll want the eggs at the same temperature to prevent them from seizing. Pancakes 2 parts flour: 2 parts liquid: 1 part eggs: 1/2-part fat Baker Move: Slowly incorporate the liquid into the dry ingredients while whisking constantly for effortless, lump-free pancake batter. Meringue 2 parts sugar: 1 part egg whites or 1 part sugar: 1 part egg yolks Baker Move: Avoid cracks in your perfectly piped meringues by keeping your oven door closed while they dry out. Yep, that means no peeking. Pie Dough 3:2:1 flour:butter:water Baker Move: Soggy-bottomed pie crusts, be gone! Pros know to par-bake their crusts for fresh fillings. Fritter 2:2:1 flour:liquid:egg Baker Move: The key to a crispy fritter is to never crowd the pan. Drop too many in the frying oil at once and the temperature will plummet, producing a greasy, mushy fritter. Custard 2:1 eggs:liquid Baker Move: Once you have that ratio down, remember to strain your cooked custard through a fine mesh sieve to remove any lumps. Crepes 1/2:1:1 flour:liquid:egg Baker Move: Crepe batter needs time to set up, preferably overnight in the fridge. Links Cooking with Ratios Food Network Previous Next

< Back Wound Care American College of Surgeons: Home Skills for Patients Adult Colostomy/Ileostomy - collection of resources to help you prepare for managing your ostomy, including videos and a home skills kit. Your Colostomy/Ileostomy Ostomy Home Skills Kit: Adult Colostomy/Ileostomy Wound Management Home Skills Program Drain Care Jackson-Pratt (JP) Drainage Tube: After Hospital Care [Northwestern Medicine] Previous Next

< Back Guts on the Floor and Exposed Spine Patient #1 A 32-year-old male was involved in a head-on motor vehicle collision. He was ejected and pinned between two vehicles. He was brought in by EMS and on arrival to the trauma bay, he was covered with a sheet. When he was transferred to the gurney, it was clear that there was something unusual. He was eviscerated with a large wound in his right lower abdomen just above his inguinal ligament, and his intestines were entangled in his clothing. Patient #2 A patient was brought in by EMS following a motorcycle accident with a report of "exposed spine". Primary survey unremarkable, hemodynamically stable. FAST revealed fluid in the abdomen. A secondary survey revealed multiple extremity abrasions. When the patient was log rolled, he was noted to have a full-thickness degloving injury of the soft tissue and partial avulsion of the back musculature with exposed spinous processes. What are the management priorities? Prioritize primary and secondary survey, treat life-threatening injuries first. Secure airway. Evaluate for concomitant injuries, including thoracoabdominal injuries, requiring emergent surgical intervention. The challenge of Distracting injuries Remember- very painful or frightening injuries may distract from pressing clinical priorities. Regardless of how horrifying or novel an injury is, the goal of rapid evaluation and management of trauma patients is to identify and treat the most life-threatening injuries first. Remember to evaluate the airway, breathing, and circulation, and don't be concerned with the exposed intestine until you have ensured the patient doesn't have a pending loss of airway, tension pneumothorax, cardiac tamponade, etc. Control active arterial hemorrhage. Don't let the patient die from an unsecured airway while you are frantically attending to grass and flecks of wood and rock covering the exposed back muscle overlying the spine. Previous Next

< Back Snowboarding Gear and Resources I currently ride a true twin snowboard. Brand- Arbor Cadence Size- 147 cm Profile- System Rocker What kind of board I'm looking for? All-mountain Shape- directional twin Profile- rocker/ reverse camber Flexibility- medium Website Links On the Snow Up-to-date information about snow conditions. Projected resort opening/ closing dates. State Level Information- V irginia Snow Report Specific Resort Information- Jay Peak Apps On the Snow (see above) Epic Pass Slopes How to Choose a Snowboard Snowboardingdays.com REI.com How to Set Up Your Snowboard Burton.com Mounting Burton Bindings Miscellaneous Seven Most Dog-Friendly Ski Resorts in North America Previous Next

< Back ICU Society of Critical Care Medicine (SCCM): Patient and Family Resources Meet the Critical Care Team Learn about the members of the ICU care team. Patient Communicator Application This free app by SCCM is designed to improve communication between patients, families, and caregivers. Critical Care FAQs Learn about which patients require care in the ICU, what things commonly happen in the ICU, as well as find a more detailed explanation of common medical conditions seen in the ICU. Resource Library The MyICUCare.org Resource Library includes complimentary materials aimed at educating patients and families about the critical care journal, both during an ICU stay and after discharge. Understanding Your ICU Stay: Information and Patients and Families booklet. American Thoracic Society- Patient Education | INFORMATION SERIES Managing the Intensive Care Unit (ICU) Experience: A Proactive Guide for Patients and Families Mechanical Ventilation What is Acute Respiratory Distress Syndrome? What is ECMO? Central Venous Catheter Arterial Catheterization What is Hemodialysis for Acute Kidney Failure? What is Sepsis? Palliative Care for People with Respiratory Disease or Critical Illness Tracheostomy in Adults Living with a Tracheostomy Venous Thromboembolism- Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) Preventing Venous Thromboembolism [John Hopkins Medicine: Armstrong Institute for Patient Safety and Quality ] Previous Next

8 Freakanomics A Rogue Economist Explores the Hidden Side of Everything - Hard to include all the different topics under one umbrella. Very controversial topics, such as crime, cheating, the impact of a name. - Correlation versus causation. Does legalized abortion lead to decreased crime? Using broad generalizations, people who grow up with mothers who didn't want them are placed in circumstances that increased their likelihood of involvement in crime. Previous Next

< Back Definitions Common Abbreviations ACS- Acute care surgery. Field of surgery that encompasses trauma, emergency general surgery and surgical critical care. APP- advanced practice provider. Includes physician assistants (PA) and nurse practitioners (NP). ICU- intensive care unit. Higher-acuity (sicker) patients requiring closer monitoring (continuous evaluation of vital signs), more invasive or more frequent interventions (mechanical ventilation, multiple cardiac medication infusions). CRNA- certified registered nurse anesthetist. CRRT- continuous renal replacement therapy. EGS- Emergency General Surgery. GCS- Glasgow Coma Scale. IV- intravenous. MCC- motorcycle crash/ collision. MVC- motor vehicle crash/ collision. SCC- surgical critical care. Common Personnel - Attending physician- most senior physician caring for a patient. - Bedside nurse- the nurse who provides the direct patient care, including assessing a patient's current clinical status, providing medications, interact with other teams that see the patient such as physical therapy or the wound care team, placing urinary catheters and monitoring urine output, communicating with the patient's physician team, providing patient education. - Chief Resident- resident in their final year of residency training. - Fellow- a physician that has completed preliminary training and undertakes advanced training in a subspecialty. Typically follows residency graduation, although Surgical Critical Care can be completed prior to graduating from surgical residency. - Intern- a physician in their first year of residency training following medical school graduation. Common Procedures - Arterial line placement- similar to an IV, this is a skinny catheter, but instead of being in a vein, it’s placed in an artery. This allows continuous monitoring of blood pressure and allows repeat labs, specifically arterial blood gas to assess respiratory status. - Bronchoscopy- use of a small camera (think of a really skinny colonoscope) to examine the airways of the lungs, take a specimen for culture or remove an obstruction. - Central line placement- placement of a large catheter into a large vein in the neck, under the clavicle (collarbone), or in the groin. The purpose is similar to an IV (intravenous) line, which is commonly placed to provide medication, fluids, or draw blood. A central line is larger- more drips can be connected to it, it can be kept in place longer than a peripheral IV, and it can allow delivery of special medications. - Intubation- placement of a plastic breathing tube (endotracheal tube) through a patients mouth, into their trachea (airway). Patients receive sedation medication and paralytic medication (medication to prevent muscle movement. This is commonly used for patients who are unconscious or are having breathing difficulties. It is also commonly used while patients are undergoing surgery - Laparotomy- vertical incision on the abdomen to allow examination of the organs in the abdomen. Also known as an “exploratory laparotomy” or “ex lap”. - Ostomy creation- in the unplanned setting, patients who undergo emergent surgery for trauma or bowel ischemia/ perforation, a segment of the bowel might be removed, reconnected or repaired. These patients are at a higher risk for their bowel connection or repair to fall apart (known as an anastomotic leak). To prevent this, sometimes it is safer to divert the stool toward an opening in the skin to allow stool to pass outside into a bag, instead of moving into the intestine that was repaired/ reconnected. - Ostomy reversal- reconnection of the bowel after a patient has recovery from emergency surgery. The bowel is reconnected (so the patient will now pass stool normally) and the skin opening is closed. - Percutaneous endoscopic gastrostomy tube (PEG)- creation of a connection directly through the anterior abdominal wall into the stomach to allow feeding without requiring a tube in the patient’s nose. - Thoracotomy- incision on the chest to allow access to the organs in the chest (heart, lungs, esophagus). - Tracheostomy- creation of a connection directly from the front of the neck to the trachea (airway). A short curved tube is placed in the open, and the endotracheal tube (breathing tube) is removed from the mouth. Common definitions - Rounds- the process of evaluating and examining patients currently in the hospital. Previous Next

Things I don't want to do (or do again) Anti-Bucket List Things I don't want to do (or do again) Experiences I don't care to repeat, but glad I did them once Tough Mudder Eaten alligator and shark Things others want to do that I have no desire to do Skydiving Scuba diving Attend the Masters Previous Next