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

< Back The Trauma Bag Why was there a need for a trauma bag in the hospital? As an acute care surgeon responding to trauma activations, airway emergencies, and a variety of other hospital surgical emergencies, there are a handful of supplies that I always have with me. The two basics are a scalpel for surgical airways and trauma shears (classically used to remove clothes in the trauma bay, but I seem to find more uses all the time). Eventually, I added a Kelly clamp to my armamentarium- handy for disconnecting or unscrewing a wide variety of impossibly tight connections or securing something in place. During the COVID Pandemic, numerous changes were made in our hospital to minimize infection transmission. Unfortunately, several of the modifications had unintended negative consequences. When we stopped wearing white coats, we lost our pocket space for stashing scalpels and shears. We also carried more gear, including eye protection and N-95 masks (carried in a brown bag when not worn). Many surgeons adapted by using an assortment of bags, such as sling backpacks or CamelBak cases. My own choice is this fanny pack , which draws many compliments! The next challenge was the relocation of supplies from the wall of our trauma bay onto shelves in the hallway. Team members had to leave the trauma bay, locate which cart the item was on, and then scan for the item, which created delays. This disrupted communication as well because team members missed changes when they were outside the room. Another hurdle that existed even before the pandemic was the array of different names for the same item. Most people who place cotton-tipped applicators in their ears after their shower call them by the brand name “Q-tip”…they are actually called “cotton tip applicators” or “CTA”. **Note- don’t use Q-tips in your ears!** Drop the Q-tip! Why ENTs are begging you to leave your ears alone. The surgeon might ask for 4x4s, which is what we call gauze in the operating room. Some say "Quik-Clot” while others know the product by the name “Combat Gauze”. Sutures are a whole other bag of worms…do you use silk or Ethibond to secure your chest tube? Curved or straight needle? Countless times, the trauma chief is managing the trauma and when someone calls for a suture, their attention is often diverted to advising the person reaching into the suture box on the wall.…"no, the one to the left, top row." It’s not always easy to tell from the box what the suture and needle look like. In addition to the elimination of white coats, relocation of commonly used supplies outside the trauma bay, and different names for supplies, I noticed that several key items were frequently used and they seemed to be unreasonably challenging to locate in a timely fashion. Combat Gauze, Coban, specific suture on a specific needle, etc. Therefore, I created a backpack of supplies that I carry when on call. What does this bag do? This bag was created from my perception of a necessity to ensure specific supplies are readily available when responding to surgical emergencies. A Level 1 trauma center is equipped with the highest level of resources and personnel to manage the most complex patients, and our resources and patient population dictate what supplies are needed on a routine basis. My focus was on supplies that are (1) frequently used, (2) unique and not readily available in all locations where they are used, and when they are required, (3) delays in employment are remarkably morbid, and (4) portable. Why didn’t I include tourniquets? They’re frequently used and delays in employment are morbid, but patients typically have them in place on arrival and if not, they are readily available in the trauma bay. Why didn’t I include chest tubes? They are frequently used and delays in employment are morbid, but they are relatively widely available. In addition, the life-threatening physiology of hemothorax or pneumothorax can be resolved with a finger thoracostomy using a scalpel and Kelly (essentially the same process as placing a chest tube, but stopping at the step of a finger sweep in the thoracic cavity, releasing massive hemothorax or tension pneumothorax). Why didn’t I include a REBOA kit? This is a controversial topic. However, in the situation where resuscitative thoracotomy is deferred in favor of REBOA, rapid employment is ideal. However, this device is not frequently used at our facility. Paper clips? In a trauma bag? Yes, paper clips. They are used to mark wounds for creating a road map of the trajectory. What DOESN’T this bag do? This is NOT an all-inclusive bag for responding to all emergencies. It should not be considered a guide for pre-hospital emergency response, non-surgical emergencies, or any situations outside of the specifications reviewed above. There are other response teams in the hospital that have different supplies. For example, we have ICU nurses that respond to rapid response or code blue situations, and they carry critical care transfer bags. I don’t know the list of supplies that they carry, but here is a sample of potential contents of a “transfer bag”. In summary, my trauma bag is focused on specific needs that I perceived based on my daily work at my facility. If you perceive a need for a similar tool at your facility, I would encourage you to develop a supply list tailored to your needs. Trauma Bag- Supply List Personal Protective Equipment Blue gown, non-sterile (2) Medium gloves Mask with eye shield (1) Sterile Supplies for Procedures Pack of blue towels (1) Stapler (1) Sterile gown (1) Small Chloraprep (2) Laceration tray (1) Dressings and Hemostatic Agents Gauze, 4x4 (2) Surgicel, 2 in x 3 in (4) Quik-Clot, 3 in x 4 yds (3) Kerlix, 3.4 in x 3.6 yds (3) Kerlix, 4.5 in x 4.1 yds (1) Coban, 4 in x 5 yds (1) Large Tegaderm (4) Sutures and Instruments #1 Ethibond, curved needle (8) #0 Silk, straight needle (4) #0 Silk, curved needle (1) #2-0 Silk, curved needle (2) #2-0 Vicryl, curved needle (5) Skin stapler (1) Adsons (1) Kelly clamp (2) Needle driver (1) Laceration tray (1) Scalpel #10 (1) Scalpel #11 (1) Miscellaneous Cotton tip applicators (3) Tongue Depressors (2) Paper clips Disclaimer: This was created early in the pandemic, while I was a fellow at a different institution. Previous 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

A response to the Tweet about being offended by being referred to as anesthesia Don't Call me Anesthesia < Back A response to the Tweet about being offended by being referred to as anesthesia A response to the Twitter post about being offended by being referred to as anesthesia. "Dear world, Please do not call us “anesthesia”. We are not a medication. Acceptable alternatives would be: Are you the anesthesiologist? Are you part of the anesthesia team? What is your role? I’m Dr. X and you are? Thank you for your attention to this PSA." Yes, I often refer to the "head of the bed" (the anesthesia team) as "anesthesia" (or "head of the bed"). There is absolutely no disrespect associated with this. We aren’t actually under the impression that our colleagues in other specialties don’t have names. I don't walk down the hall and wave while saying "hey cardiology how are you" or "hey GI any good scopes recently". But when it’s a chaotic/ urgent situation (responding to a code, crash laparotomy, busy trauma bay), don't get offended that your name isn't at the tip of my tongue. When you walk in and I say "anesthesia is here" or ask "are you anesthesia", everyone in the room automatically understands the change in the dynamic. We all know that someone skilled in airway management and sedation has arrived. Trust me, it's not about reducing you to a bottle of propofol. We don't need your name…we need your skillset. When there is a time for conversation, I will ask your name if I don't know you. Or I'll say, sorry, I know we've met, remind me of your name. As for being in the OR. There is only one team that doesn't take breaks or have teammates that "sub in" in the OR, and that’s the surgical team. Nurses, scrub techs and anesthesia providers all have personnel that can relieve them during the game. So when I look back toward my scrub tech and see a different face, I will ask their name. But when you're on the other side of the blood-brain barrier (also known as the sterile blue drapes), I can't see your face. And again, you might change multiple times throughout the case, so don't expect me to keep tabs on who is there when I'm focused on the task at hand. That’s an unnecessary cognitive load. I have modified my practice this week. In the last step of every preoperative timeout, just before incision, everyone introduces themselves and states their role. It humanizes everyone and serves to remind us that we are on the same team. And breaks up the formality and rote practice that we fall into. Outside the OR, I still don't have the ego to be offended by being referred to as my specialty. You can call me “trauma” or “surgery” whenever you want. I’d be giddy if every time I walked into a room, people stopped and declared “trauma is here”. And every person in that room either knows me (regardless of whether they know or forgot or never knew my name) or doesn't know me. But my name is irrelevant- the patient is the priority. Previous Next

10 < Back Research Resources Literature Search PubMed . National Library of Medicine, database to search for biomedical and life sciences literature. Cochrane Library . Leading journal and database for systematic reviews in health care. For a more extensive list of surgical and critical care references, please see Medical Literature . References Zotero . Free computer program that organizes all your medical literature. Highly recommend. You can create folders and add tags to help index your documents. If you want to sync your documents across devices (phone, tablet, etc), you can purchase a storage subscription. 2 GB costs $20/ year, 6 GB costs $60/ year and $120/ year gives you unlimited data storage. Tools and shortcuts in Zotero: Automatically add articles from any electronic resource (PubMed, journal website, etc). Easily tag and sort documents into categories to help easily locate articles on a particular topic. Search your entire database of documents for any author, title, year of publication, and journal source, and perhaps most usefully- search for any individual words to find a comprehensive list of documents that address a particular topic. There is a note panel on the right side of the document that allows you to type a note while reading the article. Automatically create a note from the text you highlight while reading an article. Alternatively, if you choose to type your own notes, you can also highlight text and add a single highlighted section to the note. EndNote . Free application that simplifies citation management. Use Cite While You Write to embed references while writing manuscripts. Data Analysis Covidence . Systematic review management program. It requires a subscription. GraphPad QuickCalcs . I do NOT endorse this as the most reliable/ valid/ precise options for doing statistics. HOWEVER, I have used it for simple calculations and it always matches or is incredibly close to what my formally trained statistician reported. PubMed . National Library of Medicine, database to search for biomedical and life sciences literature. Cochrane Library . Leading journal and database for systematic reviews in health care. Research Manuscript Submission Manuscript Title Page Template .docx Download DOCX • 49KB Manuscript Cover Letter Template .docx Download DOCX • 49KB Previous Next

< Back GERD What is GERD? Gastroesophageal Reflux Disease (GERD), more commonly known as heartburn, is caused by acid from the stomach moving into the esophagus, which causes a burning pain in the middle of the chest. Anatomy After swallowing, food moves down the esophagus and into the stomach. The lower esophageal sphincter (LES), which is at the connection between the esophagus and stomach, prevents stomach contents from moving back into the esophagus. The lower esophageal sphincter is located below the diaphragm, where pressure from the abdominal organs helps keep the sphincter closed. There are different causes of GERD, but the lower esophageal sphincter is key to preventing reflux. See below for more details about why GERD occurs. Source: UpToDate Images: Gastroesophageal Reflux (GERD) Causes of GERD Decreased pressure of the lower esophageal sphincter- if the lower esophageal sphincter is too loose/ relaxed, stomach contents move more easily into the esophagus. This can be a pre-existing condition but it can also be caused or worsened by lifestyle habits. For example, tobacco and certain foods such as alcohol, chocolate, caffeine, carbonation, mint, citrus/ tomato-based foods, spicy/ fried/ fatty foods, can also decrease the pressure of the sphincter. Eating too much/ too fast→ overfilling the stomach leads to increased pressure, causing stomach contents to be pushed into the esophagus Laying flat- when you are standing or sitting upright gravity helps avoid reflux by keeping food in the stomach, but when laying flat, stomach contents can move into the esophagus more easily. This is why symptoms are often more severe at night or first thing in the morning. Hiatal hernia - when the lower esophageal sphincter is able to move into the chest, it no longer has the external pressure normally present when it’s in it’s correct position, and it more easily allows stomach contents to move into the esophagus. See link for image. Obesity or pregnancy- increased pressure on the abdomen from excess weight can put pressure on the stomach and allows stomach contents to move into the esophagus for easily. GERD: Symptoms and Causes [Mayo Clinic: Patient Care & Health Information] Diagnosis Symptoms are often adequate to diagnosis GERD. A swallow study can provide further information. This study is performed in radiology, and involves drinking contrast material and having x-ray images taken to evaluate the esophagus and stomach while you swallow. This study can diagnose esophageal problems, such as poor muscle function leading to swallowing difficulty. In addition, a hiatal hernia can be identified. John Hopkins Medicine: Barium Swallow An esophagogastroduodenoscopy (EGD), also known as an upper endoscopy (see link) can be used to assess the inner lining of the esophagus, stomach and the first part of the small intestine (duodenum). There are many things that can be identified on an EGD, but specifically related to GERD, damage to the lining of the esophagus and the presence of a hiatal hernia can be identified with an EGD. Patient education: Upper endoscopy (Beyond the Basics) [UpToDate] Upper Endoscopy [Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)] Additional testing can be performed based on symptoms, results of initial testing and response to treatment. Esophageal manometry- a study to evaluate the muscle function of the esophagus ( pH test- a study to evaluate how much acid the esophagus is exposed to, which is one measure of the severity of GERD. GERD: Diagnosis and Treatment [Mayo Clinic: Patient Care & Health Information] Treatment Lifestyle Modifications [ Patient Handout: Anti-Reflux Diet and Lifestyle Modifications ] Eat slowly, avoid eating large meals and stop eating before you feel full. Avoiding alcohol, chocolate, caffeine, carbonation, mint, citrus/ tomato-based foods, spicy/ fried/ fatty foods. Avoid lying down for at least 2-3 hours after meals. Don't snack after dinner/ before bed. Elevating the head of the bed by 6-8 inches. This is NOT done by placing multiple pillows under your head- multiple pillows would actually increase pressure in the abdomen (like doing a sit-up or crunch). For more information, see this guide from the Kingsley clinic. Lose weight. Stop smoking. Avoid tight-fitting clothing. Medication Over the counter antacids Prescription medication Surgery Depending on how well medication and lifestyle modifications improve your GERD symptoms, and depending on the results of your other studies, such as your swallow study, esophageal manometry and pH testing, surgery may be an option for GERD. UpToDate Patient Education Patient Education: Gastroesophageal reflux disease in adults (Beyond the Basics) Previous Next

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

< Back AKI...pending Management of Acute Kidney Injury Previous Next

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< Back Blast- Multiple Penetrating Injuries A 32-year-old male soldier sustained a severe blast injury with a chest wound and a supraclavicular wound, a tangential right shoulder wound, and right hand wounds. He arrives at the hospital for care. He was awake and alert, hemodynamically normal. A secondary survey revealed these wounds. Injury Pattern What are the possible injuries based on this wounding pattern? Intra-thoracic (cardiac, pulmonary), great vessels/ right subclavian vessels Next steps in evaluation? Extended FAST exam to evaluate for fluid in chest, abdomen, and pericardial space. CXR to identify for retained foreign body. Helpful to place radio-opaque markers on wounds to help establish trajectory. Plain film of chest/ upper abdomen What additional injuries are possible based on these wounds and imaging? Any organ in the path of the wounds can be injured- this includes intra-abdominal structures (small and large bowel, stomach, spleen, kidney), retroperitoneal structures (kidney) and the diaphragm. How do we determine which body cavity to explore first? Hemodynamic stability and wounding pattern can direct how to proceed. A hemodynamically unstable patient requires swift intervention concurrent with ongoing resuscitation, while a stable patient can be approached more deliberately. The clinical exam can suggest which body cavity is causing the instability. Peritonitis, abdominal distension, grossly positive FAST in the abdominal views suggest the abdomen as the site of injury. Signs of thoracic injury causing instability include decreased breath sounds, jugular vein distension, muffled heart sounds, fluid on pericardial view of the FAST fluid, and a large volume of bloody output in the chest tube. In addition, location of projectiles on plain film help determine trajectory, and any structures along the trajectory can be injured. This patient was managed in a deployed environment by an austere surgical team. We did not have access to CT imaging and we had limited capacity for continuous monitoring. Therefore, in order to rule-out cardiac and intra-abdominal injuries, we performed a midline laparotomy. We performed a pericardial window through the laparotomy. There was no fluid in the pericardium. We performed an abdominal exploration. There were no intra-abdominal injuries. Wounds in the Cardiac Box In the classic description, the “cardiac box” is bordered superiorly and inferiorly by the sternal notch and the xiphoid process, and laterally by the nipples. However, thoracic gunshot wounds outside these confines can just as readily result in a cardiac injury. The diagnosis of cardiac injuries starts with a physical exam and FAST. Physical exam findings can include hemodynamic instability, muffled heart sounds, and jugular venous distension (Beck's triad). FAST will reveal pericardial fluid. If the patient is awake, they may be panicked and have an impending sense of doom. Penetrating cardiac injuries require operative repair. FAST Examination Online Tutorial Society for Academic Emergency Medicine SAEM FAST Exam YouTube Video Previous Next

The emotional stress and challenges of ACS I could never do your job < Back The emotional stress and challenges of ACS René Leriche, “Every surgeon carries within himself a small cemetery, where from time to time he goes to pray—a place of bitterness and regret, where he must look for an explanation for his failures.” Acute Care Surgery is not an easy profession. My time as a surgical critical care fellow challenged me in ways I never predicted. The challenges of this field are numerous, although not all are unique to acute care surgery. Historically, trauma surgeons worked long hours (with the associated sleep disruptions), unpredictable workloads managing a mixture of high acuity critically-ill and injured patients, high patient mortality rates, and frequent exposure to horrifically injured patients.(1) Despite my intense desire to pursue this, I didn't truly grasp the depth of the emotional toll I would face. I am incredibly grateful to the mentors who guided me during my fellowship. I have told plenty of family members about the death of their loved one. There is a palpable difference between the interaction with a family of a patient you never knew- someone who came in unresponsive or someone who died shortly after arrival. It’s tragic, without a doubt, and it’s never easy to tell a family about this unexpected loss. But managing patients in the ICU, you have the opportunity to talk to them, to learn about them as real people, to meet their family. There are a few specific patients and family conversations I will never forget. After a busy week during the winter holidays, I was already emotionally drained. Friday morning, I sat in a large room full of family members and had to break the news that their loved one had become significantly sicker overnight. Unfortunately, he continued to deteriorate, and the following day, I had to tell them there was nothing else we could do. From my viewpoint, all human life is valuable. Sometimes it seems incredibly hopeless, which leaves us feeling helpless. It took me a while to gather myself for the second conversation with that same large family. I confided in my attending that I didn't think I could get through the conversation without tears. Thankfully, she gave me the gift of acceptance- she told me that I had established rapport with the family, and it was okay to cry. She also reminded me that I wouldn't have to give a long speech because they would already know that it wasn't good news. I am grateful for the opportunities I had to witness intense conversations between senior trauma surgeons and various critical care physicians and patients and families. I learned lots of critical care and patient management, the principles of managing multiple critically ill patients, and advanced operative techniques of trauma and emergency general surgery. But I am most grateful for the "art of medicine" that I learned from my mentors, which can't be taught in a textbook. Learning how to deliver bad news and help families navigate the difficult decision-making process are vital skills in this profession. This is a challenging specialty. It demands expertise in multiple clinical disciplines, the skill to manage multiple critically ill patients and the ability to balance contradictory needs of competing organ dysfunctions in one patient. Thankfully, with a good team of senior surgeons, you can navigate the nuances while training to practice this honorable profession. 1. The Committee to Develop the Reorganized Specialty of Trauma, Surgical Critical Care, and Emergency Surgery. Acute Care Surgery: Trauma, Critical Care, and Emergency Surgery. J Trauma. 2005;58:614 –616. Previous Next

7 When The Scientific Secrets of Perfect Timing - We should capitalize on our natural circadian rhythms. What is your chronotype? - Premortem. Examine what you think could go wrong. Not getting a book written. Think of what could cause it. Not writing every day. Not keeping the editor updated. Think of how to change those to positive actions. He wrote six days a week and consulted his editor regularly. - Techniques for promoting belonging in your group? Email response time is the single best predictor of whether employees are satisfied with their boss. - Syncing to the heart- working in harmony with others makes it more likely we will do good. Previous Next