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< Back Don't mess with the Pancreas A 47-year-old female with epigastric abdominal pain and nausea presents to the ER for evaluation. She is an otherwise healthy female, with no prior surgical history. On further questioning, her pain started 3 days ago and radiates toward her back. It has persisted and wasn't relieved with over-the-counter Tums, Gas-X, and Pepcid. She has had nausea but no vomiting. She has had minimal appetite over the past few days. Her history is otherwise unremarkable with no prior similar symptoms. On exam, she is uncomfortable but not in acute distress. HR 112, BP 112/63, T 99.1, O2 sat 99% on room air. Her abdominal exam is notable for focal tenderness in the epigastrium. What is on your differential and what is your initial workup? Peptic ulcer disease, esophagitis, hepatobiliary pathology (cholecystitis, hepatitis), pancreatitis, bowel obstruction, GERD, and bowel perforation. Labs- CBC, amylase, lipase, lactate. Imaging- acute abdominal series, possibly CT scan. Her labs are notable for a WBC of 11K, markedly elevated lipase, normal bilirubin and normal renal function. Her acute abdominal series shows non-specific bowel gas pattern with minimally dilated loops of small bowel. Right upper quadrant ultrasound revealed gallstones without evidence of acute cholecystitis. Based on the patients clinical presentation and lab findings, she is diagnosed with acute gallstone pancreatitis and was admitted to the surgical service. What are your initial goals of management? Pain control, IV fluid resuscitation. NPO until pain is improving. NGT if nauseated/ vomiting. Monitor vitals and organ function (urine output, labs). On her second hospital day, she developed worsening nausea/ vomiting, so an NGT was placed to decompress her stomach. Over the next few days, she has ongoing low grade sinus tachycardia, and then she developed intermittent low grade fever and mild leukocytosis. At that point, a CT scan is obtained. CT abdomen and pelvis https://video.wixstatic.com/video/3b6ff6_7d78015ba7b5430bb996145d60f8b0d6/360p/mp4/file.mp4 The scan reveals peripancreatic inflammation with peripancreatic stranding, gland edema and hypoperfusion. There is also simple appearing peripancreatic fluid. Over the next few days, the patient developed worsening pain and an uptrend in her leukocytosis. She is mildly hypotensive and she is urinating less frequently. When a Foley catheter is placed, she has a small volume of concentrated urine in the collection bag. She is transferred to the ICU and a Dobhoff tube was placed for post-pyloric enteral feeding. Over the next two days, she develops fevers, an increasingly oxygen requirement and persistent pain. A repeat CT scan was obtained. Follow-up CT abdomen and pelvis https://video.wixstatic.com/video/3b6ff6_e3134e03b3f242a291efd6dbc2e187e2/360p/mp4/file.mp4 There is evidence of progression of her pancreatitis. There are bilateral pleural effusions as well as worsening intra-abdominal free fluid. There is evidence of non-perfusion of the midportion of her pancreas, consistent with pancreatic necrosis. She remained in the ICU over the next several days. She did not clinically deteriorate and her pain slowly resolved. She had persistent high-volume output from her NGT. Why would she have high volume output in her NGT? Gastric outlet obstruction from peripancreatic fluid collection or necrosis. Ileus from ongoing intra-abdominal inflammation. Her distension improved with NGT decompression, and she continued to have bowel function. She was started on post-pyloric enteral feeds via a nasojejunal tube, and this was continued for the next month, awaiting for the acute necrosis to wall-off and develop a rind. Management of Acute Pancreatitis Etiology Gallstones and alcohol account for the vast majority of cases of pancreatitis. Other causes include hypertriglyceridemia, medication, ERCP, and hypercalcemia. Diagnosis Clinical presentation- epigastric pain, sometimes radiating to the back or shoulder. Nausea/ vomiting. Labs- elevated amylase/ lipase at least 3x normal Radiology- peripancreatic inflammation on contrast CT of abdomen. CT scan is not always mandatory on admission, but its commonly obtained for patients who have significant enough disease that they warrant a surgical consult. CT is also useful to rule out other pathology if the diagnosis is unclear. Clinical Course Most patients (about 80%) with acute pancreatitis suffer only mild disease and have resolution of symptoms without sequalae. The remaining 20% progress to moderate or severe pancreatitis, which is defined by the development of peri-pancreatic fluid collections or necrosis (sterile= moderate, infected= severe), or organ failure (transient= moderate, persistent= severe). Patients with organ dysfunction require ICU admission. Initial management Fluid resuscitation and ensuring adequate pain control. Nutritional support is also important, and patients are allowed to eat. Enteral nutrition should be initiated if the patient doesn't have adequate intake over the first few days. Close monitoring for development of sequalae. Patients are at risk for ARDS, abdominal compartment syndrome and infection. Assessment of Disease Severity Ranson's Criteria: Classic criteria for estimating pancreatitis severity[1] Admit data: WBC >16K, age >55, glucose >200, AST >250, LDH >250 48 hours: ↓Hct >10%, ↑BUN >5, Ca <8, PaO2 <60, Base deficit >4, >6L IVF. CT Severity has also been used to grade pancreatitis- inflammation, fluid collections and necrosis.[2] Management of Complicated Pancreatitis- Fluids Collections, Necrosis, Infection Diagnosis and Classification of peri-pancreatic fluid collections and necrosis [3] Acute interstitial edematous pancreatitis Less than 4 weeks, the fluid collection is an acute peripancreatic fluid collection . After 4 weeks, it becomes walled-off/ encapsulated and is a pancreatic pseudocyst . Acute necrotizing pancreatitis [non-enhancing pancreatic parenchyma] Less than 4 weeks, the fluid collection is an acute necrotic collection . After 4 weeks, it becomes walled-off/ encapsulated and is walled-off necrosis . Infected pancreatic necrosis- diagnosed by air in the necrosis, clinical symptoms consistent with infection and confirmed by aspiration and culture. A negative culture does not definitely rule out infection, so in the appropriate setting of clinical deterioration, there must be a high index of suspicion for infection. Indication for Antibiotics Antibiotics are NOT indicated for severe pancreatitis or pancreatic necrosis as a prophylaxis for infection.[4, 5] They are only indicated in known or highly-suspected infected necrosis. The antibiotics chosen must penetrate pancreatic tissue to be effective- quinolones and carbapenems are both broad-spectrum antibiotics (cover gram positive and gram negative) that penetrate pancreatic tissue. Carbapenems also cover anaerobes. Metronidazole covers gram negatives. Regimen: carbapenem or quinolone + metronidazole. Also consider antifungal coverage in severely ill patients.[6] Diagnosis of Infected Necrotizing Pancreatitis Infected pancreatic necrosis can be a challenging clinical diagnosis because the inflammatory state associated with pancreatitis can present with similar signs and symptoms, including fever, tachycardia, leukocytosis and ileus. CT evidence of air in the pancreatic necrosis is highly suggestive of infection, although absence of air does NOT definitively rule out infection. Fine-needle aspiration (FNA) can be used to obtain a sample for culture. There is a risk of infecting a sterile necrotic collection by performing an FNA, so this requires careful clinical decision-making. Management of Infected Necrotizing Pancreatitis These patients need broad spectrum antibiotics. Some patients may improve with antibiotics alone, but a drainage procedure is often needed. Percutaneous IR drain placement has a low rate of complications, but frequently fails to fully resolve the infection. Upsizing the drain or proceeding to more invasive intervention (see below) is required if that patient deteriorates despite drain placement and antibiotics. Previously, open necrosectomy was the standard. This is a highly morbid procedure, that requires maintaining an open abdomen, repeat washouts, and a prolonged ICU stay. Now, the step up approach is being increasingly utilized to manage these patients less invasively with similar or better outcomes (percutaneous retroperitoneal drainage or endoscopic transgastric drainage, endoscopic necrosectomy, followed by retroperitoneal necrosectomy).[7-10] Management of peri-pancreatic fluid collections [11-13] Enteral nutrition and pain control. A trial of a regular diet is appropriate, but if the patient is able to tolerate a regular diet, supplemental nutrition is required. Enteral nutrition is ideal, as it is associated with improved outcomes compared to TPN. Enteral access distal to the 3rd portion of the duodenum may theoretically avoid stimulation of the pancreas, but there is no evidence that jejunal feeds are superior to gastric feeds. However, depending on the location of the fluid collection, gastric outlet obstruction is a potential complication. Ideally, post-pyloric access would be obtained prior to obstruction, and can be used for long-term feeding while the fluid collection is allowed to resolve/ mature. Most resolve without intervention. As long as the patient is not systemically ill, drainage of pancreatic necrosis should be delayed as long as possible, ideally 6-8 weeks. Goal is to avoid procedural intervention until the fluid/ necrosis have become walled off, and then only intervene if the patient remains symptoms (pain, early satiety). However, if the patient clinically worsens, earlier intervention is necessary. Open pancreatic necrosectomy is associated with significant morbidity and mortality. An algorithm starting with least invasive (percutaneous or endoscopic drainage) and progressing to more invasive if the patient continues to do poorly is associated with decreased morbidity and mortality. References Ranson JH et al. Prognostic signs and the role of operative management in acute pancreatitis. Surg Gynecol Obstet. 1974 Jul;139(1):69-81. Balthazar EJ et al. Acute pancreatitis: value of CT in establishing prognosis. Radiology. 1990;174(2):331-336. Banks PA et al. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013 Jan;62(1):102-11. Dellinger EP et al. Early antibiotic treatment for severe acute necrotizing pancreatitis: a randomized, double-blind, placebo-controlled study. Ann Surg. 2007 May;245(5):674-83. Leppanieme A et al. Executive summary: WSES Guidelines for the management of severe acute pancreatitis. J Trauma Acute Care Surg. 2020 Jun;88(6):888-890. Howard TJ. The role of antimicrobial therapy in severe acute pancreatitis. Surg Clin North Am. 2013 Jun;93(3):585-93. van Santvoort HC et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med. 2010 Apr 22;362(16):1491-502. van Brunschot S et al. Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial. Lancet. 2018 Jan 6;391(10115):51-58. Luckhurst CM et al. Improved Mortality in Necrotizing Pancreatitis with a Multidisciplinary Minimally Invasive Step-Up Approach: Comparison with a Modern Open Necrosectomy Cohort. J Am Coll Surg. 2020 Jun;230(6):873-883. Boxhoorn L et al. Immediate versus Postponed Intervention for Infected Necrotizing Pancreatitis. N Engl J Med. 2021;385(15):1372-1381. Tyberg A et al. Management of pancreatic fluid collections: A comprehensive review of the literature. World J Gastroenterol. 2016 Feb 21;22(7):2256-70. van Dijk SM et al. Acute pancreatitis: recent advances through randomised trials. Gut. 2017 Nov;66(11):2024-2032. Maurer LR et al. Contemporary Surgical Management of Pancreatic Necrosis. JAMA Surg. 2023;158(1):81. Previous Next

Websites to Bookmark < Back Technology #1 Websites to Bookmark Working with PDFs PDF Converter. All the things you could ever want to do with a PDF. Create, convert, edit, split, combine, etc. How to add links to a PDF PDF Outliner . $4.99. Easily add a table of contents to facilitate searching large PDFs. Available on Mac. iAnnotate PDF . $9.99 Most user-friendly program to view and make notes on PDFs. Available on iPad. Designs 99Designs by Vista. Logos, website development, graphic design and more! I hired a designer to create my logo for my LLC. Tailor Brands. Inexpensive program to create a simple logo. I created my first logo with this company. Near endless variety. And you can download icons optimized for social media platforms (Facebook, Twitter, Instagram), application platforms (Apple and Android), and various other programs (Pinterest, Quickbooks, Etsy, Linkedin, Meetup, Youtube). Design Program- Canva. An incredible free resource for designing creative and eye-catching social media products- videos, posters, blog posts, logos, flyers, etc. I have made YouTube videos and book covers on this platform. Lots and lots of extra features in the subscription version. Miscellaneous Diagrams . Open-source software for diagram and flowchart creation. User-friendly program (website) for creating any diagram, flowchart, or table that you desire. I have used it for everything from creating clinical management algorithms to draft a PRISMA flow diagram for a systematic review. You can save templates and download the final products. Time and Date . Create personal calendars. Calculate the number of days between two dates. Embed a PowerPoint on your Wix site . A nice tool that I learned about while making this website. Grammarly. Proof-reading program. Available as an add-on for Safari, embedded application for Microsoft Word, and free-standing application on Mac. Calendly . Free online appointment scheduling software. How to: How to read a newspaper article behind a paywall - https://archive.is/ www.nytimes - archive.ph/paste the URL Previous Next

Video Tutorials < Back Technology #3 Video Tutorials Excel for Mac: How to Import Data From a Web Page Previous Next

< Back Unusual Case of Peritonitis A 23-year-old male presents to the ED with several days of abdominal pain. He is otherwise healthy and denies any other symptoms. On exam, he has diffuse peritonitis, but no other obvious findings. He is tachycardic with a heart rate in the 110s-120s. His blood pressure is 100s/60s. No significant medical or surgical history. No remarkable events recently. He had plain films of his chest and abdomen. Plain film of the chest and upper abdomen What's going on? Differential diagnosis? Perforated hollow viscus- gastric or duodenal ulcer, bowel obstruction leading to perforation, procedural complication (EGD, ERCP). On further questioning, the patient endorses a recent soccer game during which he blocked a goal and was hit in the stomach. Unsure if it was the soccer ball or a kick to the stomach. He then had a CT of his abdomen and pelvis. CT of the abdomen and pelvis, representative slices What's going on? Diagnosis? Intervention? Free air (pneumoperitoneum) and free fluid are consistent with a perforated hollow viscus. No clear source on the CT. This requires abdominal exploration. We proceeded with exploratory laparotomy. Found liters of succus. There was a single perforation of the small bowel that was resected and anastomosis was performed. The abdomen was closed and a drain was placed. Intraoperative Findings Management of Peritonitis from Perforated Hollow Viscus The hollow viscus refers to the gastrointestinal tract from the esophagus to the rectum. Pain associated with hollow viscus perforation is classically acute onset, constant, severe, and worse with movement. The peritoneal lining of the abdomen becomes inflamed in reaction to the leaking enteric contents. This is a surgical emergency. The diagnosis can be made with the visualization of pneumoperitoneum on an upright chest x-ray (lucency under the diaphragm). A patient with peritonitis and free air requires surgical exploration. A CT scan can help identify the underlying pathology, but is not mandatory and should not delay operative intervention. Non-operative management is reserved for the patient with a sealed perforation (example- retroperitoneal duodenum) or a patient who is a prohibitively high-risk operative candidate (example- patient on palliative or hospice care). Cultural differences Not all cultures have adopted the practice of Western medicine. In some cultures, people still seek advice and medical care from traditional healers. Unfortunately, this can delay treatment if a patient requires operative intervention. Some of the treatments provided by traditional healers can also lead to further injury. This patient with a small bowel injury was seen by a traditional healer several times before he was finally brought to the hospital. The marks on his skin are the result of a practice of cutting the skin to heal the cause of his abdominal pain. Another patient was brought to the hospital for a severe infection of his genitalia. By the time he came to the hospital, his infection was so extensive that he required a debridement of a large portion of the skin in his perineum. He had been seeing a healer who was treating him with a topical solution that had essentially burned his skin, so in addition to the underlying infection, he had severe tissue damage. Previous Next

Overcoming barriers while teaching and being humble as a consultant Tackling the expertise bias < Back Overcoming barriers while teaching and being humble as a consultant Why is it so hard to remember what it was like before you knew the things that you now consider fundamental, basic knowledge? If you are a teacher, which includes school teachers as well as everyone responsible for passing knowledge to others, self-reflection on how you relay information and assess comprehension is paramount. One common challenge is overcoming the "curse of knowledge". The curse of knowledge takes hold and becomes a hurdle when the teacher/ instructor assumes that their audience has the same background knowledge and should be "up to speed" without significant delay. In other words, there are many things you do every day that you consider obvious and second nature. It is exceedingly easy to be quick to judge your trainees for not recalling or readily grasping those concepts. How has this manifested itself in my experience as a teacher in the ICU? Caring for patients with a wide breadth of physiologic derangements is a rich environment for interactive real-time learning. Invasive mechanical ventilation is a perfect opportunity to learn about respiratory physiology. Learning how to pick the right mode/ settings and how to make adjustments to optimize each patient's oxygenation and ventilation (while avoiding further lung injury) is key to good critical care for the patient that requires respiratory support. My understanding of mechanical ventilation was the culmination of many hours and long months/ years spent reading, preparing lectures, tinkering bedside with ventilators, engaging in dialogue with experts, and just immersing myself in the weeds. At some point, and I have no idea when it was precisely, it finally clicked. I didn't become an omniscient guru. But after enough practice, the fundamental concepts finally became solidified in my mind, and managing ventilators has become second nature. Ventilator management is a cornerstone of ICU care. Whenever there are patients that require ventilation beyond perioperative indications, I capitalize on the opportunity to teach. Even though I'm acutely aware of how much work (seemingly endless hours of work) went into learning the finer points of ventilators, it's still hard to remember what it was like before I understood. Please note- this phenomenon is NOT limited to in-person teaching. This barrier can infiltrate lectures, manuscript writing, and a variety of other forms of communication and interaction. Another situation relevant to the medical profession- the consultation with a specialist. If you're on the receiving end of the consult, it can be easy to fall into the trap of assuming everyone should have the same knowledge you have. It's crucial to remember that you are an expert in YOUR field- if the physician calling you had the same knowledge, you would be obsolete. So how do you overcome this hurdle? Here are my suggestions 1. The first step is to acknowledge that your interactions can be impacted by your bias. You know more than your students, or the person that's calling you for a consult. More specifically, you know more about what you're teaching your student and you know more about the clinical situation than the person consulting you. That's why you're the teacher and the consultant. 2. Take time to reflect on how you interact when teaching- do you rapidly become impatient, roll your eyes, reply with condescension or snark, or simply look at your students like they're idiots? Pause in real-time: it doesn't have to be awkward, and I'm sure your audience will appreciate a moment to pause and think. 3. Take the opportunity to put the shoe on the other foot. Reflect on what it was like when you were learning- as an intern struggling to remember how to replete electrolytes, a young resident in the ICU struggling to understand ventilators, or even a young attending struggling in a high-stress operative case. How would you want to be approached/ treated? 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 Pneumothorax American Thoracic Society- Patient Education | INFORMATION SERIES What is a Spontaneous Pneumothorax? Tube Thoracostomy (Chest Tube) You have a pneumothorax. This happens when your lung collapses and there is air in your chest. This can be spontaneous but is also frequently secondary to trauma. Imagine your lung is a balloon. When there is a hole in the balloon (penetrating wound to the chest, rib fracture, etc), the balloon collapses. When you breath in, the air moves from your airway, into the balloon and then out into your chest, the space around your lung. A chest tube is placed to evacuate the air from your chest and allow your lung (the balloon) to reexpand. As long as the hole in the lung is small, removing the air is generally all that is required. This is because when the lung is stuck back up to the inside of your chest, air stops leaking into the space around your lung. Surgery is infrequently required for management of a pneumothorax. This occurs when the lung fails to reinflate despite placement of a chest tube. It can also be required if there is an “air leak”. An air leak is the result of the ongoing leakage of air from the lung into the chest. The air that moves into the chest continues to be evacuated into the chest tube, and this is seen as bubbles in one window of the chest tube drainage canister. Spontaneous pneumothorax is often due to apical blebs, which are small areas at the lung of your lung that have thinned out and can rupture, with a similar results as a traumatic hole in the balloon that is the lung. Previous Next

< Back Shakshuka- A North African Dish Ingredients 1 large red bell pepper, thinly sliced 1 large yellow bell pepper, sliced 1 red onion, sliced 3-4 garlic cloves, diced ¾ tsp salt cracked pepper to taste 1 tsp cumin 1 tsp sugar ½ tsp smoked paprika ½ tsp chili flakes 3 medium tomatoes diced small ⅓ c white wine or water 1 T fresh basil ribbons or chopped Italian parsley 4 -6 Extra large organic eggs Other optional additions: crumbled feta or goat cheese 1 C browned chorizo ¼ C finely diced spanish style cured Chorizo or Merguez, a North African spiced sausage Instructions 1. Preheat oven to 400F. 2. In a large cast iron skillet, heat the olive oil over medium heat. Add the onion and cook until tender, about 5 minutes. If adding raw chorizo, brown it with the onions. 3. Add the sliced peppers and garlic, and turn heat down to med-low and cook for 5 more minutes, until peppers are tender. If adding the cured spanish chorizo or Merguez sausage, add it now. Add all spices, sugar and salt. Cook for 2 more minutes. Add fresh tomatoes and white wine. 4. Simmer on low for 15 minutes, adding more water if it gets too dry or thick- you want a stew-like consistency. After tomatoes cook down, taste, it should be full flavored- adjust salt and sugar if necessary. Crack 4-6 eggs over the mixture, sprinkling each egg with salt and cracked pepper. Add crumble goat cheese or feta over the top and place in the 400F oven. 5. Bake until egg whites are cooked (about 7 minutes) and yolks are still soft. Remove from oven and top with fresh basil (or Italian parsley). Serve with toast or crusty bread. Veggies sizzling Previous Ready for the oven Yummy! Next

Brain Death and Organ Donation End of Life Issues < Back Brain Death and Organ Donation Death can be uncomfortable and challenging to face/ navigate. Here are some of the situations that can arise surrounding the issue of death and organ donation. - Is resuscitating a patient with a devastating TBI for organ donation preservation justified? It may seem opportunistic and NOT focused on the dignified care of the patient- but it the patient’s desire would be to donate, preserving that option DOES honor their wishes. - If a patient is declared dead, specifically brain dead or death by neurologic criteria, and they previously expressed desire to be an organ donor (such as registration with an OPO or indicating their desires on their drivers license), legally the family can’t prevent the patient from donating. Even if the family opposes it, legally the patient should proceed to donation. But what about the risk of “bad press”? You’re honoring the patients wishes although that fact may be less apparent to the public compared to the anger expressed by the family members that the hospital “stole their loved one’s organs against their wish” or even worse, implying that the hospital “allowed” the patient to die so they could use their organs. - You don't need consent to perform a brain death test. Previous Next

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