< 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

Measuring Cups and Spoons < Back Kitchen Hacks #2 Measuring Cups and Spoons Cooking versus baking…what's the difference? Technically cooking is a general term encompassing all manners of food preparation. But cooking is typically used to indicate a style that doesn't involve baking. Baking is a science that requires attention to detail and precisely measured ingredients that often have to be combined in a specific order. Recipes for baked goods frequently indicate weight in ounces (which required a small countertop scale) as well as volume (measured in your dry measuring cup). On the other hand, cooking allows on-the-fly modifications- it's much more forgiving to small variations. Baking requires precise measurements- so you'll need a variety of dry and wet measuring utensils. If you're unfamiliar with baking, here is a quick summary of how to measure dry and wet ingredients. What are dry measuring cups and how do I use them? These hold the exact amount of an ingredient (you fill these to the top). Either spoon the ingredients into the cup or scoop the cup into the container holding the ingredient (ie wide-mouthed containers). Fill to the top without packing, and level off the top (knife, the handle of a cooking utensil, chopstick, whatever you have). The only ingredient that gets packed is brown sugar- otherwise, unless the recipe specifically mentions packing, don't pack! What are liquid measuring cups or beakers and how do I use them? These have graduated indicators to allow pouring an exact amount of liquid, and the top measurement is below the top of the cup (no spills when pouring). Why can't I just use dry measuring cups for liquids? If you use a dry measuring cup for liquid, it will be very challenging to avoid spilling the ingredient when adding it to the recipe (remember, dry cups get filled to the top). What can I measure with a measuring spoon? Fortunately, these can be used for both dry and wet (although if you have beakers with small measurements, you can also use those for measuring out liquids). Warning about dry ingredients. If a dry ingredient is specified by weight (ounces), this cannot be converted to cups! 8 ounces of flour ≠ 8 fluid ounces of liquid, which is 1 cup of liquid. If you want a visual of the range of what 1 cup of dry ingredients can weigh, check out this extensive list . Previous Next

< Back More Information on Acute Care Surgery The Beginnings of Acute Care Surgery: A Paradigm Shift in Surgical Emergencies. Nelson BV and Talboy GE. Acute Care Surgery: Redefining the General Surgeon. Mo Med. Sep-Oct 2010;107(5):313-315. Acute Care Surgery from the perspective of acute care surgeons. Santry HP et al. A qualitative analysis of acute care surgery in the United States: It’s more than just “a competent surgeon with a sharp knife and a willing attitude.” Surgery. 2014 May;155(5):809–825. A detailed timeline of our history. The AAST History of Acute Care Surgery . Previous Next

Mac, Microsoft and PDFs < Back Technology #2 Mac, Microsoft and PDFs Mac Keyboard Shortcuts Close application= ⌘ + Q Switch between applications= ⌘ (press + hold)+ Tab (press + release) Screenshot (whole screen/ part of screen)= Shift + ⌘ + 3/ Shift + ⌘ + 4 Record your computer screen= Shift + ⌘ + 5 Page up/down= FN + up arrow/ down arrow Jump to top/bottom of document= FN + Command + left arrow/ right arrow Undo/ redo= Control + Z/ Control-Y Select all= Command + A [⌘ + A] Copy/ paste highlighted text= Command + C/V [⌘ + C/ ⌘ + V] Finder New Finder Window= Command + N [⌘ + N] Close All Open Finder Windows= Command + Option + W [⌘ + ⌥ + W] Safari Autofill Webpage= Shift + Command + A Switch between tabs= ⌘ + 1 (2, 3, etc) Microsoft Word Bold/ italicize/ underline highlighted text= ⌘ + B/ ⌘ + I/ ⌘ + U Add hyperlink= ⌘ + K Expand all hyperlinks (Word)= Fn + Opt + F9 Insert footnote/ endnote= ⌘ + ⌥ + F/ ⌘ + ⌥ + E Microsoft Excel Select all cells= ⌘ + A Select row= Shift + Space Select column= Ctrl + Space Hide rows/ columns= ⌘ + 0 / ⌘ + 9 Edit text in active cell= Ctrl + U New line of text in active cell= ⌥ + Return Format currency/ percentage= Ctrl + Shift + $/ Ctrl + Shift + % Insert current time= ⌘ + ; Insert current date= Ctrl + ; Links for How-Tos Mac keyboard shortcuts Create keyboard shortcuts for apps on Mac Microsoft Tips and Tricks Microsoft Word Keyboard Shortcuts Make different lines View all Abbreviations in a document Create and format a customized list style Save the current list style as a template to use in other documents Changing Level in a List Create embedded bookmarks and hyperlinks Format an image to be integrated with text versus between sections Change Text Formatting Microsoft Excel Keyboard Shortcuts Count cells- empty, data, specific data Combine text from multiple cells Highlight cells with specific data Creating a customized drop-down list Create a dependent customized drop-down list Microsoft PowerPoint Add Text to the slide background of a PowerPoint presentation Center an image Portable Document Format (PDF) [Mac Only] Combining PDF Documents Combining PDFs in a specific Order Modifying PDF Documents Microsoft Tips and Tricks .pdf Download PDF • 2.77MB Previous Next

< Back ACS Fellowship Is Acute Care Surgery the right specialty for you? If you are considering a career in Acute Care Surgery, it's important to explore the profession thoroughly before making any decisions. While there are numerous resources available to help you make an informed decision, one of the most valuable resources is speaking with surgeons who currently practice in this field. Experiences can vary widely at different hospitals, so don’t rely on just one opinion. Acute Care Surgery is a challenging specialty that will test you in ways you may never have imagined. It requires a high level of expertise in multiple clinical disciplines. As a surgical critical care fellow, you will face many challenges, such as long working hours, unpredictable workloads managing a mixture of high acuity critically-ill and injured patients, high patient mortality rates, and frequent exposure to severely injured patients. These challenges are not unique to Acute Care Surgery, but they are particularly profound in this field. One of the most significant challenges of this specialty is the emotional toll that it can take on practitioners. Managing patients in the ICU requires a high degree of empathy and compassion, and you will be required to deliver bad news to families and help them navigate difficult decision-making processes. It can be incredibly challenging to witness the suffering of patients and their loved ones, and it's essential to have a good support system in place to help you manage the emotional demands of the job. Despite these challenges, many surgeons find Acute Care Surgery to be an incredibly rewarding profession. Through their work, they have the opportunity to make a significant impact on the lives of their patients and their families. They develop strong relationships with patients and their loved ones, and they have the opportunity to witness the resilience of the human spirit in the face of adversity. If you are considering a career in Acute Care Surgery, it's essential to be well-prepared for the challenges that you will face. Seek out opportunities to speak with surgeons who practice in this field and learn from their experiences. Develop a strong support system that can help you manage the emotional demands of the job, and focus on developing the critical skills that are required to be successful in this challenging and rewarding specialty. With the right preparation and mindset, you can make a significant difference in the lives of your patients and their families as an Acute Care Surgeon. How do I become an Acute Care Surgery fellow? While there are many one-year surgical critical care and two-year trauma/surgical critical care fellowships available, it's important to note that as of 5 October 2020, there were only 28 AAST-approved Acute Care Surgery Fellowships. The application process for these fellowships is centralized through SAFAS . This means that you will need to enter standard personal information, test scores, and personal statements. Additionally, you will need to obtain several letters of recommendation. After you submit your application, programs will contact you if they are interested in offering you an interview. When applying for these fellowships, it's important to cast a wide net and not limit yourself to just a few programs. This may seem daunting if you are applying during your final year of residency, and you are likely already very busy with patient care, managing your team, preparing for board examinations and completing the documentation required for residency completion. Before the COVID pandemic, fellowship interviews were in-person. This was expensive and time-consuming. Virtual interviews may ease this burden, but it’s still a time-consuming process. While you may have a short list of your top choices, I would encourage you to consider a broader range of options. Some programs have online resources that can provide valuable information about the program's strengths and focus areas. When selecting programs, consider your own priorities. Are you looking for a strong critical care focus or a high volume of operative trauma cases? Do you have specific research goals? Fellowship is a short and intense period of focused training to allow you to develop the clinical knowledge and procedural skillset to thrive in this field, so be prepared to commit yourself fully to this opportunity. It's important to note that no program will be a perfect fit for everyone. However, if you approach the application process with an open mind and invest time in your search, you can find a fellowship that sets you on a path towards a fulfilling career in acute care surgery. Helpful Websites AAST ACS Fellowship Applicants . Website with more detailed information about what an Acute Care Surgery Fellowship entails. Approved Acute Care Surgery Fellowships . American Board of Surgery . National organization for board certification in General Surgery, as well as subspecialties including Vascular Surgery, Pediatric Surgery, Surgical Critical Care, Hand Surgery, Surgical Oncology, and Hospice and Palliative Medicine. This is one example of the experience of an ACS fellow at a Level 1 trauma center with a well-organized fellowship program and a well-developed research team. Please refer to " How to get involved " for more information. Clinical Work 12 months of critical care based rotations 8 months of trauma/ surgical critical care (TICU/ SICU) 1 month of cardiac surgical critical care 1 month of medical critical care (MICU) 1 month of Emergency Department Ultrasound training 2 weeks with Nephrology 2 weeks of Research 12 months of surgical rotations 6 months of trauma 3 months of emergency general surgery (EGS) 1 month of transplant surgery 1 month of vascular surgery 1 month of cardiothoracic surgery Research and Publications Two IRB approved research protocols. Lead author on 4 submitted manuscripts. 2 peer-reviewed publications (one as first author). Accepted literature review. Published personal essay. Sub-Investigator on Chest Tube Insertion Trial Author of a book chapter on thoracic trauma management in the ICU Presentations Presented basic science research at AAST Conference Presented process improvement project at department level research symposium Presented a personal essay presented at the EAST conference Nine formal department level lectures. Multiple ICU team lectures. Educational Opportunities Attended operative rib fixation training course Attended training course on IVC filter placement Attended two AAST conferences and one EAST conference Attended critical care/ trauma outcomes committee meetings and trauma morbidity and mortality conferences Attended quality improvement symposium Involvement with local and state trauma advisory committee meetings Previous Next

< Back Mentorship What is mentorship? Mentorship is a partnership between a more experienced and knowledgeable individual (mentor) and a less experienced individual (mentee) seeking to learn, develop skills, and advance their career in the healthcare profession. The mentor is typically someone who has achieved a level of success that the mentee aspires to reach. Through this relationship, the mentee, who could be a medical student, trainee (resident or fellow), or junior staff member, can benefit from the mentor's expertise and past experiences, gaining valuable insights into the healthcare profession. The mentor can serve as an advisor, consultant, or coach depending on the mentor's expertise and the mentee's needs. For example, a mentorship relationship can be designed to help the mentee improve clinical skills, navigate the job search process, or advance research endeavors. It's common to have different mentors for different purposes, as each mentor may have different strengths. Mentorship also provides networking opportunities, as the mentor can facilitate connections between the mentee and other professionals in the field. In summary, mentorship is a valuable tool for professional development in healthcare, offering guidance, support, and connections that can help mentees achieve their goals. Do I really need a mentor? Throughout medical school and residency, I didn't have any formal mentors, but I did actively seek the opinions, advice, and feedback of several surgeons I respected. As a young staff surgeon, I still didn't actively pursue mentorship, though I now recognize that it could have been highly beneficial. My first formal mentorship relationship was late in my training, when I was an Acute Care Surgery fellow and I was required to choose a staff member as a mentor. It's not uncommon for trainees to lack mentors, and one possible explanation resonates with me. "Many young people today who end up in residency…have been on a fast track. They’re essentially high-achieving, highly driven professional students who have been on a fairly regimented pathway…and they haven’t reached a point where there are multiple pathways they could take."(1) As someone who has been on a straight path since high school, progressing from high school to medical school to residency to being a junior faculty, I potentially missed out on a valuable asset. It's important to note that having a mentor is not a requirement, but developing a strong relationship with a mentor can positively influence one's success. It's highly recommended that individuals consider formal mentorship, but it's equally important to recognize that they have the ability to end relationships that are toxic or not a good fit. How do I find a mentor? Mentorship relationships can be an essential aspect of professional growth for medical trainees. These relationships can develop organically or be assigned by program directors in residency or fellowship programs. If you are assigned a mentor, it can be a great experience, but it is also possible that you may not mesh well if the assignment was not carefully considered. It's essential to recognize that if you find yourself in a mentor-mentee relationship that is not productive, amicable, or beneficial, it's okay to end the relationship and seek out another mentor. On the other hand, organic mentorship relationships can also be incredibly fruitful. As you work with various individuals in different settings, such as the operating room, during rounds, or while discussing consults, you will begin to form opinions and may find that you gravitate towards a particular person. If you respect and trust them and they demonstrate skills or expertise that you want to learn from, they might be a viable option as a mentor. The process of finding a mentor can be as simple as asking the person you would like to work with if they would be willing to mentor you. Remember, the worst they can do is say no, so it's worth taking the risk to ask. If they don't have the time to commit to being a mentor, they may be able to connect you with someone else who could be a good fit. It's important to recognize that mentorship relationships require effort from both the mentor and the mentee. While your mentor can offer guidance, support, and feedback, it's ultimately up to you to take ownership of your own professional development. Be clear about your goals, seek out feedback, and be receptive to constructive criticism. By putting in the work, you can make the most of your mentorship relationship and set yourself up for success in your career. Finding a mentor can be a great way to help you achieve your personal and professional goals, but it's important to have a plan in place to make the most of the relationship. Here are some steps you can take after finding a mentor to ensure that you get the most out of the relationship: 1. Set specific goals: Take some time to think about what you hope to gain from your mentorship. Are you looking to improve your skills in a particular area? Do you want help navigating a career transition? By setting specific goals, you can make sure that you and your mentor are on the same page and working towards the same objectives. 2. Establish communication: Once you've set your goals, it's important to establish how you will communicate with your mentor and how frequently you will meet. This can be done through formal meetings, phone calls, or casual chats over coffee. Make sure that both you and your mentor are comfortable with the frequency and type of communication. 3. Complete assignments or tasks: Your mentor may assign you tasks or provide you with guidance on specific projects. It's important to take these assignments seriously and complete them as directed. This could be anything from revising your CV to drafting a study protocol. By following through on these tasks, you can demonstrate your commitment to the mentorship and make progress towards your goals. 4. Reassess and refine: As you work with your mentor, it's important to regularly reassess your progress and refine your goals. This may involve checking off completed tasks, adding new objectives, or removing items that are no longer a priority. By keeping your goals current and relevant, you can make sure that you are making the most of the mentorship. Overall, finding a mentor can be an incredibly valuable experience. By taking the time to set goals, establish communication, complete assignments, and reassess your progress, you can make sure that you get the most out of the relationship and achieve your personal and professional objectives. 1. Darves B. Physician Mentorship: Why It’s Important, and How to Find and Sustain Relationships. NEJM Career Center. 2018 Feb. Previous Next

Tips and Tricks from a Novice < Back Starting a Business Tips and Tricks from a Novice *Disclaimer* This is all information from my own personal experience. The materials available on this website are for informational purposes only and not to provide legal or financial advice. Please consult a legal or financial expert to obtain advice for any particular issue or problem. TL;DR Choose what type of business entity to start- *research the legislation of your particular state* Register your business name Request EIN Download copies of tax forms Identify NAICS Open business bank account Create template forms- invoice, contract, waiver, receipt, etc Create a spreadsheet for tracking inventory, invoices, payments, etc Save all paperwork and receipts Create standard language for email communication (responses to inquiries, replies to potential clients, advertising messages, etc) and a standard signature block. Maintain consistency- logo, colors, language, font, etc. A few months ago, I embarked on the journey of starting my own business. Before I started this endeavor, I knew very little about business- I knew about limited liability companies (LLC) because my dad has his own LLC. I started my search from scratch, literally googling different derivatives of "business owner". Here's what I found out in my research and while I was creating my own sole proprietorship. There are a few different types of business ownership, including sole proprietorship, partnership, corporations, and limited liability companies (LLC). Specifically, individuals can form an LLC or create a sole proprietorship. These different entities vary based on their reporting requirements, paperwork, etc. Business regulations are not standard nation-wide, so you need to research your state regulations. I eventually decided to proceed with a sole proprietorship. One of the key differences between a sole proprietorship and an LLC is the distinction between the business and the owner. **Remember, it's important to do your research on the laws in your state. ** An LLC theoretically offers more protection- the general principle is that an LLC is separate from the owner. If an LLC is sued, they can't access your personal assets. A sole proprietorship doesn't offer the same boundaries. Sole proprietors have a single owner with complete control over the business, including profits and business decisions, and that individual is also responsible for all debts. The sole proprietorship is not a separate entity from its owner, and therefore it is not taxed separately. In other words, sole proprietors report income and expenses on the proprietor's federal individual income tax. One piece of advice I was given is that an LLC gives more credibility to your business. Personally, I don't think my clientele will be more likely to work with me if I added the designation "LLC" to my business name. In my opinion, given the nature of my business, my medical credentials/ board certification/ degrees are the biggest source of my credibility. MD, FACS, board-certified, etc- these mean something in the medical community. To create a sole proprietorship, I registered my business name and requested a federal employer identification number (EIN). An EIN is not required by the Internal Revenue Service (IRS) for a sole proprietorship- I don't think it's required on my tax forms. However, all the banks I contacted require an EIN to open a business bank account. After registering my business name, I downloaded copies of the tax forms that are required. It helped me understand what would be expected when filing taxes. Much less intimidating than waiting until tax time. Next, I identified my business category as described by the North American Industry Classification System (NAICS). The NAICS is comprised of many categories and sub-categories of business industries, such as construction, utilities, food services, arts and entertainment, real estate, or education. According to the IRS website "NAICS is frequently used for various administrative, regulatory, contracting, taxation, and other non-statistical purposes…Some contracting authorities require businesses to register their NAICS codes, which are used to determine eligibility to bid on certain contracts." Personally, I was required to identify my NAICS when I opened my business bank account. The next step is opening a business bank account. A separate bank account is necessary to distinguish your personal business income from your wages (if you have another job). First, you have to make sure your bank supports business accounts. For anyone who uses USAA for your banking needs, please take note that USAA does NOT support business accounts and you'll need to establish an account with another bank. The process of meeting with a bank manager to set up my bank account was very educational- I learned about the difference between ACH, quick deposit, and wire transfers. Those are the initial steps to having a legitimate business. The next few things help boost your credibility by creating a distinct brand. I initially had one website, which was mostly educational, with a single page for my business. My moniker evolved naturally- docrot was my username in medical school. This eventually morphed into Doc on the Run, which has been my Instagram name for years and became my Twitter handle over a year ago. Initially, my business name was "ABS-CE Prep with Doc on the Run", which was my moniker. Eventually I scaled this back to ABS-CE Prep. While I was still "ABS-CE Prep with Doc on the Run", I decided to make a logo. I used Tailor Brands , which is a user-friendly platform for developing a unique branding and logo. I chose an icon and font to create a simple but distinct logo. Consistency is important. As mentioned in my website creation post, I used the same color scheme for my logo and my website. Using a 6 digit hex code ensures that my blue text and red icon in my logo are the same as the red and blue on my website. Next, depending on your business, you will likely require at least a few standard forms. My business is service-based. I needed a template for invoices and receipts, as well as a standard contract/ waiver to be signed before beginning sessions with a client. Prior to my business name change, I used my logo on each form. Finally, if you still have questions, I recommend consulting a lawyer or business expert. Previous Next

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

1 < Back Textbooks General Surgery: Scientific Foundations Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 21st Edition, 2021. This is the detailed explanation of the science behind the practice of surgery. This is the basic science textbook I used during residency. Mulholland and Greenfield's Surgery: Scientific Principles & Practice. Previously known as "Greenfields". General Surgery: Beyond Basic Science Cameron's Current Surgical Therapy. 13th edition, 2019. Short chapters with high-yield information on every topic in General Surgery. Must-have for later in residency. Trauma Mattox Trauma. 9th edition, 2021. The trauma surgery bible. Highly recommend. Critical Care Marino ICU. 4th edition, 2013. The ICU bible. Highly recommend. Civetta, Taylor, & Kirby's Critical Care Medicine. 5th edition, 2017. A detailed explanation of physiology, diagnosis, and management. Finks Critical Care. 7th edition, 2017. Slightly less detailed than Civetta. Excellent book- not too simplistic and not painfully detailed. Evidence-Based Practice of Critical Care. 3rd edition, 2019. Reviews the literature regarding specific high yield critical care topics. Surgical Critical Care Therapy: A Clinically Oriented Practical Approach. 1st edition, 2018. Essentials of Mechanical Ventilation. 4th edition, 2018. Previous Next

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

< Back Ultrasound: Trauma E-FAST Purpose: identify acute traumatic pathology including presence of pericardial fluid, pneumothorax, and intra-abdominal fluid. Probe Can use curvilinear probe, but usually switch to the phased array for the cardiac view, so it might be easiest to just use a phased array for the whole study. The linear probe can also be used when evaluating for pneumothorax through the anterior chest wall. Abdominal Cavity Assess for fluid in 3 different regions of the peritoneal cavity. Can use curvilinear probe, but usually switch to the phased array for the cardiac view, so it might be easiest to just use a phased array for the whole study. Right upper quadrant- 1) between liver and kidney [Morrison's pouch], 2) tip of the liver in the right paracolic gutter, 3) lower right hemithorax Left upper quadrant- 1) between the spleen and kidney, 2) subdiaphragmatic space, 3) tip of the spleen in the left paracolic gutter, 4) lower left hemithorax Pelvic- males- between bladder and rectum, females- behind the uterus, anterior to the rectum (pouch of Douglas). Image in transverse and sagittal planes. Cardiac The phased-array or curvilinear probe can be used. The probe is placed inferior and to the right of xiphoid, pointed to left shoulder, with the probe in a horizontal plane (not directed to the bed). Identify presence of hemopericardium (4th trans-abdominal window of the FAST). Assess gross function (contractility). Assess volume status- full or collapsed left ventricle. Thoracic cavity- The “E” in E-FAST The linear probe is used to identify oresence of a pneumothorax. It is placed in the mid clavicular line, oriented cephalad-caudad, 3rd-4th intercostal space. Pneumothorax is present when there is lack of apposition of the pleural lining to the chest wall which leads to loss of lung sliding. Also no comet tail artifact or lung pulse, presence of a lung point (where the pleural surfaces meet, the junction between sliding and absence of sliding). The curvilinear or phased array probe can be used to identify hemothorax by visualizing fluid above the diaphragm in the upper quadrants abdominal views. References Society for Academic Emergency Medicine: FAST Exam Ultrasound Tutorial: FAST (Focused Assessment with Sonography for Trauma) scan | Radiology Nation Previous Next