Difficult Discussions Giving Bad News, #2 < Back Difficult Discussions These are NOT my original ideas. They are tidbits I garnered at the American College of Surgeons Clinical Congress in 2022. The sesions was entitled "A Multicultural Primer on Death and Dying: Improving Goals of Care Discussions for Surgical Patients Facing the End-of-Life" (PS 120). Note: These are NOT universally applicable. Please tailor your conversations for each interaction. How To Break Bad News Fire a warning shot. I'm sorry that I have some bad/ hard news to share with you. Reveal the headline. Your son came to the trauma bay after being shot/ being in an accident and I’m sorry to tell you that he died. Stop talking and be quiet after the headline. Acknowledge and legitimize their response. I recognize how hard this must be for you. Quite honestly this sucks. Other Tips and Tricks If the situation allows, you can ask the family/ patient how they like to receive information. Do they want blunt facts or generalizations? Is there a designated leader who should be the key individual that information is passed through? Note- this isn't beneficial in all situations, such as breaking the news of a family members death in the trauma bay. Avoid euphemisms and medical jargon. Tell me more about that (to encourage them to share emotions). Handling Negative Vibes If you notice tension building, either in yourself or in the room (anger, mistrust, etc), acknowledge it. Can we talk about what’s happening here? Please share your perspective with me on this. You can ask permission to share your own take on the issue. Try to find common ground- often the well being of the patient. Keep the focus on the patient. Maintaining hope and sharing the truth Hope means different things to different people and different things to the same person as they move through their illness. It’s not our job to dole out info in a way that maintains hope. It’s our job to explore what hope means to them as we share this information. Factors that can increase hope- feeling valued, maintaining relationships, time, humor, realistic goals. Adequate pain and symptom control. Factors that can decrease hope. Feeling abandoned, devalued and isolated. Don’t say “there is nothing else I can do for you”. Other Helpful Phrases Are you surprised by this conversation? That was really hard for me to say. I can only imagine how hard it was for you to hear. What would your loved one say if they could talk to us? [This lifts the decision making burden and can help them feel like they’re advocating for what their family would want]. If they’re making a decision that conflicts with your guidance? Consider asking “what are you hoping for” or what is leading you to make this decision?" Previous Next

Gadgets and Tools < Back My Favorite Things Gadgets and Tools Packing and Travel These Hopsooken packing cubes make organizing your suitcase a breeze. These noise-canceling headphones effectively drown out the rumbling noise of airplanes at a reasonable price. The Patagonia Black Hole Duffel . Multiple sizes available. Very spacious. Easily converts to a backpack when traveling for easy carrying. Therma-Rest compressible pillow from REI Quick Dry Towel from REI Cleaning Products Goo Gone - for removal of excess sticky residue. Greased Lighting - great for stain removal. It can be purchased at Lowes/ Home Depot. Kitchen Storage containers for baking ingredients. These wide-mouthed containers let you pour baking ingredients from their original bags with minimal mess. It’s also very easy to use a scoop directly into the containers when baking. This is a perfect bread box ! When I leave a loaf of bread in its original package, it gets moldy pretty quick- but if I put it in this box, it lasts much longer. Bakers Rack . My current kitchen has much less cabinet space than what I have grown accustomed to, so I sought out a solution to store my baking supplies that take up my counter space. Now my bread maker, mixing bowls, large metal colander, and rolling pin no longer hide above the fridge or clutter my counters. Writing Accessories A hand-held non-electronic datebook . After years of relying on electronic resources to maintain my schedule, I finally made the switch to a device that allows me to create/ maintain a schedule, both weekly and monthly formats. Also has blank pages at the back, perfect for lists, notes, etc. Frixion Erasable pens “We've all had a shower thought or two…They're the miniature epiphanies that occur when your brain is occupied with doing something else, but suddenly you realize that you've come up with a totally unique way of thinking.” And sadly, once we step out of the shower, the great idea seems to vanish. Thankfully, someone developed this notepaper that doesn’t fall apart in the shower! A roll of self-adhesive whiteboard paper to post to your wall, your fridge, your mirror, wherever. Handy in the kitchen- plan meals, add items to put on your grocery list when you discover you’re running low or just write reminders. My favorite highlighters when writing notes. They aren’t too heavy, so they don’t bleed or run. They are dual-tipped, with a broad highlighter on one end and a narrower tip for writing on the other end. My favorite pen . Fine tip to allow precise, small writing. Trello - a user-friendly free application with multiple functions. I use it to store frequently used documents to allow quick reference. It is also a very convenient way to create and manage lists among teams so everyone has easy access. Check it out, you might find it useful. Things for the Ladies I don’t wear many thin garments or revealing necklines, so I don’t often have to struggle to find a bra that remains concealed. However, on the rare occasion that I wear a dress or top that isn't conducive to wearing a bra, these reuseable cover-ups are incredibly handy for maintaining decency. If you're interested in making the transition from disposable monthly products, check out this product . This is the only one I've tried, so I can’t compare them, but it's worked well for me. Lume Deodorant . Doesn’t stop sweating, but eliminates odor. Highly highly recommend. If you find yourself having to unclog the shower drain with clumps of hair, you might want to check out the Tub Shroom . Previous Next

1 Trauma Lectures Ab Vasc Exposure .pdf Download PDF • 1.04MB DCR and MTP .pdf Download PDF • 42.86MB Burn .pdf Download PDF • 4.67MB Thoracic Trauma .pdf Download PDF • 69.57MB US in the Military .pdf Download PDF • 15.25MB

< Back Anorectal Disease Anorectal pain is an incredibly common condition . Thanks to our low-fiber Western diet and often inadequate hydration, constipation is a frequent occurrence. People also often spend long periods on the toilet. We used to read books, but now many play games or text on their smartphone. Constipation and prolonged sitting on the toilet can lead to several different problems. While discussing these symptoms can be awkard or uncomfortable, please talk to your doctor if your symptoms don't go away on their own. So what is anorectal pain? Although "butt pain" may be a common complaint, I want to be clear with my explanations. In reality, “butt” more accurately refers to the gluteal region, which is also known colloquially as derriere, buttock, backside, or fanny. It may be simplest to describe the butt as the area that rests on the surface of a chair when you sit. Anorectal refers to a more specific location, the anus and rectum, where stool passes through when you have a bowel movement. Please see the anatomically correct depiction below. What are the common causes of anorectal pain? Fissures Hemorrhoids Pruritis Ani Abscesses Less common- pelvic floor dysfunction, cancer Anatomy of the anus and rectum Two sphincter complexes encircle the rectal vault. The internal sphincter provides 85% of the resting tone. It is under involuntary control- this is how your body controls when you have a bowel movement. The external sphincter provides 15% of resting tone- it is under voluntary control, which means this is how you consciously control holding in a bowel movement. The internal hemorrhoids are veins that line the inside of the rectum, while the external hemorrhoid plexus is on the anal verge. These means that hemorrhoids are a NORMAL part of anatomy! They fill with blood to aid in incontinence, helping you control when you have a bowel movement. Anything that increases pressure in the abdomen, including prolonged straining, coughing, pregnancy, and enlarged prostate requiring straining to urinate, can lead to abnormally large venous plexuses, which are what most people know as hemorrhoids. See “Hemorrhoids” below for more details. Glands line the inside of the rectum and help lubricate stool. When the glands become obstructed, they can lead to abscesses. What are the common symptoms of anorectal disease? Pain Bleeding- either blood dripping in the toilet, blood on the toilet paper with wiping, and blood mixed with or on the stool's surface. Mucus drainage (constant moisture), which can cause challenges with perianal hygiene Pruritis (itching) Palpable mass Constipation/ diarrhea, incomplete voiding What causes anorectal disease? Prolonged straining or prolonged time sitting on the toilet, often due to constipation (hemorrhoids) Constipation and passing a hard stool can lead to tears in the skin (fissure) Underlying gastrointestinal disease (inflammatory bowel disease, etc.) How do I prevent anorectal disease? The goal is to improve bowel habits and minimize constipation. High fiber diet. Most Americans have a low-fiber diet, consuming way less than the recommended 20-35 grams of fiber per day. Fiber can come from dietary intake (the foods you eat) as well as supplements. Take the time to read labels. The foods we commonly think of as “high-fiber,” including lettuce, are not as fiber-rich as we think. A word of warning If you quickly add a significant amount of fiber to your diet, this can lead to gastrointestinal distress (gas, diarrhea, cramping, etc.). Add fiber slowly until you reach your goal! Stay hydrated! Fiber without adequate hydration will create hard stools (rabbit pellets), making constipation worse. The recommendation is a minimize of 64 ounces of water per day. Plain water is best, but flavoring with Crystal Light, lemon, or lime can make it more palatable. Listen to your body regarding bowel movements. Hold it until socially acceptable, but don’t hold for longer than necessary. But just as important, don’t force a bowel movement if you don’t feel the urge. Some people may be trained to try to have a bowel movement before leaving for work- if this works for you, that’s fine. But don’t let the clock dictate when you have to use the bathroom. Minimize the amount of time sitting on a toilet. Prolonged sitting increases pressure, which predisposes to pathology. If you are still having challenges, consider investing in a device to facilitate improving your posture. We are accustomed to using toilets…unfortunately, sitting creates an angle that makes it difficult to have a bowel movement. Squatting, with knees elevated closer to the chest, creates a straighter path leading to more optimal conditions to have a bowel movement. Consider a squatty potty! Specific Anorectal Pathology Hemorrhoids Anal Fissures Pruritis Ani Patient Info- Fiber Guide .pdf Download PDF • 68KB Patient Info- Hemorrhoids .pdf Download PDF • 58KB Patient Info- Anal Fissure .pdf Download PDF • 59KB Patient Info- Pruritis Ani .pdf Download PDF • 58KB Patient Info- Constipation .pdf Download PDF • 54KB Previous Next

And You Really Should be Nice to People It's a Small World < Back And You Really Should be Nice to People The medical community is incredibly small and interconnected. This can be very beneficial, but can also create challenges if interpersonal discord arises. Word travels fast and it's easy to burn bridges. In the medical field, there is a palpable tension between certain specialties. Not every hospital has the same procedure for managing trauma. However, in the countless hospitals I've worked in, clinicians in Emergency Medicine and Trauma Surgery work hand in hand to manage severely injured trauma patients. We have different training experiences and different management styles. When we (Trauma Surgery) come down to the trauma bay to evaluate a patient, we are a visitor. Yes, in a busy hospital, we might be incredibly frequent visitors. But still, we are guests in another department's home. Despite the best intentions, and perhaps even because of varying perspectives on what is "the best" intention, it is not a surprise that the trauma bay can serve as a breeding ground for animosity,(1) unless there are deliberate efforts to prevent conflict. Thankfully, creating a common language and developing standard practices is possible through mutually developed protocols, as well as principles in ATLS. This is crucial to effective patient care. I am grateful that I completed my Acute Care Surgery fellowship at a hospital system with a phenomenal relationship with our Emergency Department colleagues. I won't exaggerate and deny any conflicts, but there was a culture of mutual respect and a common goal of optimal patient care that I had never experienced before. Why Does It Matter? I started this post to share a story of why it's important to be nice to everyone you encounter. I mean, besides the fact that I believe that we should be kind and compassionate to everyone. At one facility that I worked, there was a less than friendly relationship between surgery and the emergency department. Again, I will confess that I likely had several of my own negative interactions. However, my general principle is based on what I described above. I consider my behavior and attitude to be at least a basic level of respect and decency to the providers that I interacted with. In contrast to unpleasant providers, I appeared to be above average. About 5 years ago, I was preparing for a deployment. I had the misfortune of being attacked by several dogs and required a series of rabies vaccines, which delayed my medical clearance. Thankfully, one of the ER providers from my hospital was at pre-deployment with me. He called a senior medical officer and obtained clearance so I could proceed without delay. It would have been easy for me to dismiss this provider during any of our countless interactions. If I had been consistently less pleasant, I suspect that he would have maintained a basic level of decency despite my poor behavior. But it's unlikely that he would have extended himself to advocate on my behalf. You never know what interaction could make the difference, so we should be nice to everyone. 1. Why Can't Emergency Medicine and Surgery Just Get Along? EmCrit Podcast. Previous Next

The Challenges of Being A Female (Acute Care) Surgeon Are you sure? < Back The Challenges of Being A Female (Acute Care) Surgeon My 17-year journey to become an Acute Care Surgeon started when I applied for medical school in my senior year of high school. I went to a 6-year combined-degree medical school and then completed a 6-year surgical residency. At age 29, I began my practice as a General Surgeon. After 3 years as a Staff Surgeon, during which I had one combat deployment and one medical readiness exercise in Africa, I then chose to complete an acute care surgery fellowship. Our acute care surgery department was comprised of 14 surgeons, only 3 of whom were female. Surgery has historically been a male-dominated specialty, and female surgeons continue to face significant obstacles.(1) There has been a noticeable shift with more females choosing surgical specialties, although they continue to be under-represented in trauma. This can create a sense of rivalry or competition, the need to be seen as equally competent as our male colleagues. On top of the difficulties inherent to surgical training and practice, the constant pressure to live up to expectations can foster stress and doubt. Imposter syndrome, which is "a psychological pattern in which people doubt their accomplishments and have a persistent, often internalized fear of being exposed as a ‘fraud’," can result.(2) Are You Sure This is What you Want to Do? Twelve years ago, during my internship, I was in the process of reapplying for the remaining 5 years of my surgical residency (a phenomenon that was subsequently eliminated from military surgery residencies). As I asked one of the senior (male) surgeons for a letter of recommendation, he discussed the issue with me in the middle of a busy clinic, with other residents and staff present. He asked if I was sure I wanted to do a surgery residency, and he encouraged me to consider other career paths. Thankfully, I did not experience this discrimination from any of my other staff. But I do wonder if there was discrimination of omission...were my male co-residents provided encouragement or advantages that I was not afforded? In my small residency, with a total of 18 residents, we had a total of 5 females during my first year, including another female intern. I felt encouraged that 2/3 of my class was female, but this was the exception and not the rule. Eight years ago, during my surgical residency, I was at a very busy Level 1 trauma center. I can't recall the exact ratio of male to female surgeons, but I know women were in the minority. During a non-emergent trauma case, there was a product representative in the room. During a casual conversation, he was clarifying who was the surgeon. When the senior surgeon in the room (a female), introduced herself, he actually stated "Oh I didn't know women could be trauma surgeons." In an article published in the American Journal of Surgery in 2019, half of all hospitals with emergency general surgery services reported no female surgeons. For the subset of hospitals with EGS services who have an ACS Model, they reported a higher median proportion of women surgeons (17%).(3) Specifically in trauma surgery, women are still under-represented. 28% of surgeons who are board-certified in critical care are female. Thankfully, our voice is gaining strength. More women are going into surgical disciplines, and there are more woman in leadership positions in surgical organizations.(4) 29% of EAST members and 13% of AAST members are female, although there has been an increase in female executive leaders in AAST.(5) "Why should women have to sound like men to get people to listen to them? Why isn't it that everyone in the room should be quiet when she asks for quiet because she is a doctor asking for quiet?" "The theme was clear. Women physicians do not get the same respect men get when dealing with emergencies."(6) Women bring unique strengths to this discipline. It's not a matter of competing to prove that we are superior, but women are inherently different from men and this should be nurtured, not belittled, or ridiculed. Improved communication and patient engagement are just a few of the benefits we can bring to the team. Researchers Find Women Make Better Surgeons Than Men . "The authors attribute the favorable patient outcomes to the female doctors’ ability to communicate and engage with their patients to ensure compliance with medications and therapy, their adeptness at collaborating with colleagues and their tendency to adhere to guidelines when treating patients." This is not a simple problem, and it won't have a simple solution. So what can you do to combat the stereotypes and respectfully establish and maintain your position comparable to your male surgical colleagues? I've learned a few things over the years, with a handful of specific things over the years of my fellowship. Introduce yourself with your Title and name. Previously, I introduced myself as "Christina, part of the surgical team". I regarded my introduction as a display of humility. But I was actually unintentionally undermining my role in the team. I now introduce myself as "Dr ----, one of the trauma surgeons/ acute care surgeons" or "Dr ----, the trauma surgeon/ acute care surgeon who will be taking care of you." Find your team. Seek out mentors, or be a mentor for a younger trainee. Seek support from those who have led the way in this specialty. Get involved. This can be done at all levels, from hospital-level leadership and committee membership, city/ state/ national trauma organizations/ associations Counteract the negative thoughts that can accompany Imposter Syndrome. Keep a list of your strengths and the reason why you chose this specialty. 1. Stamp N. I'm a female surgeon. I feel uncomfortable telling girls they can be one, too. Washington Post. 29 July 2019. 2. McGuire K. Imposter Syndrome: The Dirty Little Secret of Successful Women (And Men Too). Association of Women Surgeons. 3 April 2019. 3. Oslock WM, Paredes AZ, Baselice HE, et al. Women surgeons and the emergence of acute care surgery programs. Am J Surg. 2019;218(4):803-808. 4. Haskins J. Where are all the women in surgery? Association of American Medical Colleges. 15 July 2019. 5. Foster SM, Knight J, Velopulos CG, et al. Gender distribution and leadership trends in trauma surgery societies. Trauma Surg Acute Care Open. 2020;5(1):1-5. 6. Riley, Edward. Voices in the OR: A Self-Reflection and Examination of Unconscious Bias. Doximity. 28 Oct 2020. 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

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

Your Words Matter...And OCD isn't an Adjective "That's So Gay" Your Words Matter...And OCD isn't an Adjective "A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder." - DSM V (Diagnostic and Statistical Manual of Mental Disorders) Psychiatric disorders are a constellation of traits that impact a person's interaction with their environment. A formal diagnosis is based on a constellation of symptoms as well as an assessment of how functional the person is in their daily life. These disorders are outside the control of the individual, and they are pervasive in a way that interferes with daily life. We all have traits that could fit with a psychiatric diagnosis, but that doesn’t permit us to use the diagnosis as an adjective. We've all heard someone call themselves ADD because they're occasionally distracted or forgetful. People might call themselves or someone else OCD if they like a neat tidy environment. Bipolar is frequently used to describe (or insult) emotional people. What's the problem with using ADD as an explanation for occasional absent-mindedness, or calling someone bipolar because they are moody? Equating the presence of a trait of a disorder with an actual diagnosis minimizes the real struggle that many people experience every day. This is similar to using the words “retard/ retarded ” or “gay” to mean something is stupid or weird. In 2009, the Spread the Word: Inclusion campaign was created to eliminate the use of the “R-word”. In 2010, Rosa’s Law relabeled “mental retardation” to “intellectual disability”. The words “imbecile”, “idiot” and “moron” have also been relabeled as profound, severe, or moderate intellectual disability. The Stonewall Education Guides: Tackling Homophobic Language , which was published nearly 10 years ago (no date identified, but the document quoted literature published in 2012 describing “the previous 5 years”). They listed “that’s so gay” and “you’re so gay” as the two most commonly used homophobic phrases. They report that these phrases “are most often used to mean that something is bad or rubbish, with no conscious link to sexual orientation at all…a pupil might say ‘those trainers are so gay’ (to mean rubbish or uncool) or ‘stop being so gay’ (to mean stop being so annoying). Check out these PSAs discouraging people from using the phrase “that’s so gay”. "That's So Gay" Commercials Win Top Ad Council Award (starts at 1:16) Wanda Sykes Talks to Boys in a Diner Just like gay and retarded have been used out of their appropriate context to mean something is bad or stupid, here are some of the common traits that people mislabel as a "disorder" - OCD: excessive cleanliness, being overly tidy, “Type A” personality - ADHD: a tendency to make careless mistakes, forgetfulness, short attention span, easily distractable, tendency to interrupt conversations. - Depression: sadness, pessimistic, being an introvert - PTSD: bad memories associated with something trivial (the sound of a pager going off), bad dreams, fear of a particular event - Insomnia: occasional trouble initiating or maintaining sleep - Bipolar: moodiness, decreased need for sleep. - Anxiety: normal levels of anxious feelings It might not seem like a big deal- but try to imagine if you had a disorder that made normal interaction with your environment a struggle? Now imagine someone who can function normally but has a couple of “quirks” were to equate their experience with yours? You might feel that they are minimizing your disorder, invalidating your struggles- this might leave you feeling misunderstood and alone. Please think before you speak. Your words matter. Previous Next

< Back Gunshot Wound to the Leg A 26-year-old male soldier sustained a gunshot wound to the right medial thigh. He had a compressive dressing that was placed prehospital. He arrived at the hospital and underwent a rapid primary and secondary survey. Initial X-ray Evaluation? Radiologic imaging. Evaluation for extremity vascular injury. He had active bleeding from the wounds. After plain films and initial stabilization, the patient underwent operative exploration of the vascular structures of his right lower extremity. His right femoral artery was intact. His right femoral vein was transected and there was a long segment of destroyed vein, which was treated with ligation. He underwent right lower extremity fasciotomy. This was followed by femur fixation with the placement of an external fixator. Intraoperative Image Postoperative Image Management of Combined Arterial and Orthopedic Injury EAST Guidelines In this scenario, the priority is restoring distal arterial blood flow to minimize ischemia time. If there is an associated unstable fracture, blood flow can be re-established with a temporary intravascular shunt, followed by rigid fixation of the bony injury. If the arterial injury is definitively repaired, it can become disrupted with the manipulation required for rigid fixation. If the associated fracture is stable, the arterial injury can be repaired before addressing the fracture. Previous Next

3 General Surgery Lectures General Surgery .pdf Download PDF • 152.12MB Anorectal .pdf Download PDF • 1.55MB CT Scan and X-ray .pdf Download PDF • 564KB Vascular .pdf Download PDF • 13.57MB Suture .pdf Download PDF • 4.94MB

< Back A Day in the Life of an Acute Care Surgeon This is a general outline of the daily routine of an Acute Care Surgeon- it does not represent a universal experience, because every facility and every team is unique. Daily schedules vary between the different services. Some facilities have a small enough volume that all three aspects are covered by one surgeon. However, for busy facilities, there can be up to 5-6 surgeons covering the different services. There can be multiple ICU teams to manage, each requiring a surgeon. In-coming trauma might require the full attention of one surgeon, while another surgeon takes care of inpatients and scheduled cases. This is not a guide for how to set up a department- it's just a peek into what we do during the day. The day typically starts with morning report, where overnight events are discussed. This can include trauma and ICU admissions, as well as operative cases. Other significant events such as patients who required transfer to a higher level of care are also discussed. Following morning report, the different services diverge to meet with their teams, either in the OR, in the ICU, or on the inpatient wards. Trauma Service Rounds [the process of evaluating and examining patients currently in the hospital] - Residents typically see the patients first, review their blood work and their x-rays, examine them and ask them pertinent questions to report to their chief resident/ attending. The attending and the chief resident/ senior resident discuss the patients and visit patients in person. There are different practice patterns, and flexibility is required. If the same team is also covering new trauma consults from the emergency department (ED), rounds might be staggered or split based on staffing and patient volume. - Patient evaluation focuses on monitoring patients in the postoperative period, including assessment of bowel function (have you passed gas or had a bowel movement?), nutrition and oral intake (hungry, eating 1/2 of meals, nauseated), pulmonary function (performing breathing exercises), pain control, activity (working with physical therapy, walking laps, breathing exercises), examining wounds, and ruling out surgical complications. Care for patients recovering from trauma also entails communication with subspecialists, such as orthopedics or neurosurgery. Procedures - Emergent operations on new admissions- exploratory laparotomy for intra-abdominal injuries (bowel injury, severe bleeding), thoracotomy for intra-thoracic injuries (severe bleeding, wound to the heart), repair of vascular injuries (bleeding from a blood vessel). - Scheduled operations for patients on the trauma service. Consultations and New Admissions - The majority of patient consults for trauma originate in the ED. Rarely, a patient who is currently admitted to the hospital may be diagnosed with an occult injury (meaning it wasn't found on initial assessment) or a patient may sustain an injury while in the hospital. Surgical Critical Care Rounds - See “What happens during Surgical Critical Care (SICU) Rounds? for details. Procedures - Tracheostomy- creation of a connection directly through the neck to the trachea (airway) to allow removal of the endotracheal tube (breathing tube) from the mouth. - 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. - Bronchoscopy- use of a small camera (think of a really skinny colonoscopy) to examine the airways of the lungs, take a specimen for culture or remove 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. - 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 Consultations and New Admissions - Scheduled or semi-scheduled surgical cases such as complex vascular procedures (aortic surgery, carotid surgery), transplant surgery (patients receive a new liver or kidney), resection of head and neck cancer with a need for management of tracheostomy, and monitoring of muscle flap. - Emergent surgical cases such as a ruptured abdominal aortic aneurysm (thinning of the wall with eventual rupture with bleeding), bowel perforation (hole in the intestine), or any of a variety of surgical catastrophes. - Severely injured trauma patients, including patients who require close monitoring of hemodynamics (low blood pressure, high heart rate) or pulmonary status (ability to take deep breaths with severe trauma to the chest), or patients with head injuries requiring intubation. - Non-ICU patients in lower acuity units that require ICU admission for deterioration in clinical status (respiratory distress, altered mental status, hemodynamic instability). Emergency General Surgery Rounds - Similar to trauma patients as above. For patients who haven’t had surgery (uncomplicated diverticulitis or small bowel obstructions secondary to adhesive disease), close monitoring for changes in clinical status is vital. Procedures - Emergent operations on new admissions- laparotomy for bowel ischemia/ perforation (decreased blood flow to the bowel or a hole in the bowel). - Scheduled operations for patients on the emergency general surgery service, for example, reversal of an ostomy. Patients who undergo emergent surgery for trauma or bowel ischemia/ perforation sometimes require creation of an opening on the skin to allow stool to pass outside into a bag. These can be “reversed”, meaning the bowel is reconnected (so the patient will now pass stool normally) and the skin opening is closed. Consultations and New Admissions - Patient consults typically originate in the ED. Everything from abdominal pain to rectal pain to massive intestinal bleeding can prompt a phone call/ page/ text message to the Emergency General Surgery service. - Patients admitted for non-surgical diseases can develop a surgical emergency during their hospital admission. This includes diagnoses that typically prompt a visit to the ED (appendicitis, cholecystitis), but there are a host of other diagnoses that are more frequent in the hospital setting, such as C. difficle colitis. In addition to daily responsibilities, there are weekly or monthly department-wide events. - Staff Meetings - Trauma Morbidity and Mortality- discuss outcomes from trauma cases. - General Surgery Morbidity and Mortality- discuss outcomes from general surgery cases. - Grand Rounds- lectures from subject matter experts on various surgical topics. Previous Next