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3 Everybody Lies Big Data, New Data, and What the Internet Can Tell Us About Who We Really Are - The staggering amount of data available and the power to make predictions. - Internet search bars have entered society as a secret place to ask our most urgent/ personal/ embarrassing questions without risk of guilt or shame from others discovering intimate details about us. People lie on job interviews, online surveys, and almost anywhere they are at risk of being revealed, which introduces a significant bias in database queries. In contrast, there is no motivation to lie to the anonymous search bar. - Evaluating internet searches can reveal an infinite amount of information about society as a whole. Monitoring internet searches during presidential addresses, evaluating searches for unemployment offices, what to say on first dates- there is so much data that can be harnessed to understand society. Previous Next

< Back National Parks Yellowstone and Grand Tetons This is NOT by any means an all-inclusive list of things to see and places to stay. This is based on my personal itinerary. I arrived around noon on a Monday at the East Entrance to Yellowstone, and explored the eastern side of the Grand Loop that afternoon, and spent the night at Lake Lodge. Tuesday, I explored the southern side of the Lower Loop and the western side of the Grand Loop, and spent the night at Mammoth Hot Springs Cabin. Wednesday, I went horseback riding at Roosevelt Corrals, and then drove along the eastern side of the Grand Loop to the south entrance of the park and then onto Grand Tetons, spending the night at Colter Bay Village. Thursday, I spent the morning hiking around Jenny Lake, and then went whitewater rafting in the afternoon. Friday morning I departed (drove back up to the East Entrance of Yellowstone to head to Cody, Wyoming). Yellowstone Things to See *Artist Point- short walk from the parking lot, there is a lookout point with great views of the Lower Falls. Then there is a 2.7 mile hike along the “Grand Canyon of Yellowstone”. No guardrails/ fence along the route, with vertical sheer right off the trail. No narrow passings, so it’s safe as long as you are responsible. *Mud Volcano- short half mile loop, less steep to start at the southern trailhead (to the left when you are looking from the parking lot) and loop clockwise, lots of steps down at the end of the loop. *West Thumb Geyser Basin- boardwalk around multiple basins/ fumaroles. Lots of pretty colors. Right along the Yellowstone Lake. About ¾ mile walk, easy. *Old Faithful- I got here early in the morning, so parking was easy. Later, people are circling the lot. Lots of boardwalk to explore the different geysers. If you want to have a short moderately strenuous climb to the Old Faithful Viewing Area (Observation Point Trailhead)- if you face Old Faithful, walk to the right and you’ll get to the turnoff point to the Observation Point. Loops back down so you can walk amongst the geysers near Old Faithful. *Grand Prismatic Spring Overlook- this is how to see the Grand Prismatic from above. Started at Fairy Falls Trailhead parking lot, walked to overlook (maybe 1.5 miles, pretty flat, except for a brief uphill climb to the overlook), and then continued on to Fairy Falls trailhead. Also an easy flat walk, but it’s a couple miles out and back. The falls are beautiful. *Midway Geyser Basin- pretty short boardwalk loop (careful, narrow boardwalk by the Spring). You can see the Grand Prismatic Spring and Excelsior Geyser from ground level. *Lamar Valley- opportunities to view wildlife. Lodging Lake Lodge Cabins- very rustic/ simple. Just a bed, sink, shower, toilet. Mammoth Hot Springs Hotel and Cabin- slight step up from Lake Lodge. Links Yellowstone Lodging Reservations Yellowstone Park Maps Yellowstone Roads - detailed descriptions of the landmarks along each section of the roads through the Park. I used this after the trip when I forgot to note a location where I stopped to take pictures or take a hike. Best Trails in Yellowstone (AllTrails) - I got all the descriptions for the trails I planned to hike. Grand Tetons Things to See *Jenny Lake- the boat ferry takes you across the lake so you can avoid about 2-2.5 miles of walking (one-way). But you have to get there really early (like before they even open) or you’ll be waiting in line and it is probably faster to walk versus wait in line. Lots of different trail options (Inspiration Point- decent incline, Hidden Falls, etc). Lodging Colter Bay Village- slight step up from Mammoth Hot Springs. Within walking distance of two restaurants, the general store and Jackson Lake. Links Grand Teton Lodging Reservations Grand Teton Park Maps Grand Teton Roads - same as Yellowstone. Best Trails in Grand Teton (AllTrails) Maps and Guides National Park Maps National Parked National Park Service App You can download the NPS app (above)- when you open a specific park, there is an option to download for offline use. Highly recommend doing this for both parks. When you have your phone in airplane mode and you pull up the maps in the App, you can follow yourself very closely on each trail as you walk. Very very useful. Tidbits There are lots of road turnouts along the entire perimeter drive, as well as places to stop along the Yellowstone River, that aren’t labelled on the map. Military- if you show your active ID or your DD214, you get a free National Park pass. 10% military discount at park stores. There are maps at most of the large trailheads, they request a $1 donation or ask that you return the map when you finish. Things to bring (what I found helpful) Dry sack- the weather is unpredictable, so you might be out on a hike and get stuck in a downpour. Cooler- this is the one I got on Amazon, works very well. Amazon Link Bear Spray- rent it or buy it. There are a handful of pickup and dropoff locations (BearAware ). Previous Next

< Back ICU Rounding: How I Do It The ICU can be intimidating. Critically ill patients are often surrounded by machines (ventilators, dialysis, etc) and IV poles, with multiple lines and catheters extending from their face, chest, abdomen, neck, and groin. A standardized approach can help the team synthesize and interpret all the subjective and objective data to establish a diagnosis and devise a treatment plan for these complex patients. Rounding in the ICU is different from rounding on floor patients. Floor patients are typically presented in a problem-based format- they are likely to have a short list of active issues being addressed, often just one diagnosis (cholecystitis, bowel obstruction, colon cancer status-post colectomy). Patients can certainly have co-morbidities, such as diabetes and hypertension, but they are usually relatively straightforward. Presentations are briefer than ICU presentations, and largely focus on the acute surgical diagnosis. Here is an example of a surgical floor patient. 32 year old female, hospital day 2 following laparotomy for small bowel obstruction. Her pain is controlled with oral analgesics with minimal prn requirements. She is hungry and passing flatus. She is using her incentive spirometry and ambulating. She has had minimal output in her nasogastric tube. Staples are intact along her midline laparotomy incision with no surrounding erythema and appropriate peri-incisional tenderness. Labs are only remarkable for some mild hypokalemia with K 3.4. She is voiding spontaneously with adequate urine output. Plan to replete potassium, remove NGT and advance diet. In contrast, ICU patients are fragile with more physiologic derangements that threaten homeostasis. Critical illness can profoundly impact multiple organ systems and the interdependence of organ systems adds another layer of complexity. Patients can be presented in a problem-based format, like floor patients, or a system-based format. There are pros and cons to each. As mentioned, a problem-based format addresses each diagnosis (for example- cholecystitis, bowel obstruction, heart failure, pneumonia, ileus). In contrast, a system-based format addresses each organ system (for example- cardiac, pulmonary, renal, neurologic). Problem-based might seem easier on first glance, but one downside in the ICU setting is the risk of overlooking organ systems without a discrete disease process. One downside of the system-based format is the categorization of one diagnosis to various organ systems. For example, ventilator-associated pneumonia is related to the pulmonary system but overlaps with infectious disease. However, the system-based format is comprehensive and thorough, which helps ensure that all physiologic processes are considered. One advantage of the system-based format is it’s adaptability to less complex patients. While it’s challenging to apply floor round formatting to the ICU setting, once you understand how to utilize the ICU system-based model, you can use it to briefly review non-ICU patients to ensure that you don’t forget something. For a young male with cholecystitis, you don’t need to report GCS, medication infusion rates, ventilator settings, insulin requirements, etc. But the systems are still pertinent- address pain (neuro), ensure normal vitals (cardiac) and use of incentive spirometer (pulmonary), check oral intake, assess return of bowel function and examine wounds (GI), inquire about adequate urination and review BMP (renal), ensure no fever, review CBC (heme and ID), and ensure ambulation/ SCDs (prophylaxis). ICU care is a team endeavor, requiring the integration of nursing, respiratory therapy (RT), dieticians, pharmacists, physical therapy and other team members to provide comprehensive care. ICUs must implement a system to integrate care plans between all team members. This can occur in different formats, either with “prerounds” (brief discussion with multidisciplinary team about each patient before formal rounds) or with multidisciplinary rounds (team members present their key data points/ plans in a structured format). One example of multi-disciplinary rounds (abbreviated): resident reports one-liner (see example below); nurse reports their assessments (pain/ sedation scores, delirium assessment, etc); RT reports current ventilator settings, results of spontaneous breathing trials and respiratory treatments; the resident then presents the patient as below. Order of Presentation during Rounds 1. Brief one-liner [presented by the resident, APP or student caring for the patient]. See below. 2. Bedside nurse- report on sedation, pain, infusion rates, etc 3. Respiratory therapy- report on ventilator settings, respiratory interventions, etc 4. Formal patient presentation [presented by the resident, APP or student caring for the patient]. See below. 5. Pharmacist- review of medications, including potential dose adjustments, antibiotic tailoring, etc 6. Attending 7. FAST-HUG- ensure that key aspects of care are addressed (feeding, analgesia, sedation, thromboprophylaxis, head of bed elevated, ulcer prophylaxis, glycemic control) 8. Readback- nurse briefly summarizes the key goals of the day One-liner: brief patient history, acute overnight events. Example: 32 year old male, POD 7 exploratory laparotomy following motor vehicle collision, remains intubated for VAP. Formal Patient Presentation [Systems Based] Neurologic (Neuro) Diagnosis: Exam/ objective data. GCS, reflexes, pupils. ICP monitor. Medication: continuous infusions, requirements of prn analgesics Plan: Neuro- patient remains intubated and sedated, GCS 11T off sedation, currently on Fentanyl @ 100 mcg/ hr and propofol @ 20. Minimal requirements of prn analgesics. We will wean fentanyl infusion and use enteral multi-modal analgesia. Cardiac Diagnosis: Exam/ objective data. Vitals: describe the trend, know when outliers occurred (for example, an isolated heart rate (HR) of 130 during a procedure at noon the previous day is different from a sustained HR of 130s). If patient has any invasive monitoring, such as arterial pressure waveform analysis (FloTrac, Vigileo), pulmonary artery catheter or central line, include these as well. Medication: Plan: Cardiac: HR 90s-100s, Flotrac shows normal SVV. On norepinephrine, requirement is currently down to only 2 from a max of 10 yesterday, MAP goal of >65. Continue to wean norepinephrine. Remove arterial line once off norepinephrine for 12 hours. Pulmonary (Pulm) Diagnosis: Exam/ objective data: intubated, secretions, breath sounds, breathing pattern. Ventilator settings. Labs: ABG if performed. Imaging: note findings, and describe how it’s changed relative to prior imaging Medication: Plan: Example: Pulm- pt remains intubated, current ventilator settings. CXR still shows bilateral fluffy infiltrates. *on antibiotics day x of x for VAP, CXR worsening/ stable, secretions improving. Then, later: ID- patient is on antibiotics day x of x for UTI, and day x of x for VAP. Gastrointestinal (GI)/ Nutrition Diagnosis: Exam/ objective data: abdominal wounds, drains, stool management system, bowel function, nutrition. Medication: bowel regimen Plan: GI- patient started on tube feeds two days ago, but he’s having minimal stool output. Abdomen is distended and tympanitic. We held feeds this morning and have an abdominal plain film pending. Renal/ Fluids/ Electrolytes (Renal) Diagnosis: Exam/ objective data. IV fluids. Intake/ output. BMP. Medication: Plan: Renal- foley in place with good urine output, I/O 3.2L/2.9L. No continuous IV fluids. Electrolytes within normal limits. Hematologic (Heme) Diagnosis: Exam/ objective data. Labs: Hgb, Plt. Transfusion. Medication: Plan: Heme- stable mild anemia, checking CBC every Monday/ Wednesday/ Friday. Infectious Disease (ID) Diagnosis: Exam/ objective data. Labs: WBC, neutrophils. Culture results (sample source, date, results). Medication: current antimicrobials. Plan: ID- patient is on antibiotics day 2/5 for UTI, and day 2/5 for VAP. He has remained afebrile for the last 48 hrs. His WBC is downtrending. No pending cultures. Endocrine (Endo) Diagnosis: Exam/ objective data. Labs: glucose trend, insulin requirements Medication: Plan: Endo- stress hyperglycemia, glucose range from 210-240. Currently on SSI with 24 hr requirement of 22U. Increase to more aggressive sliding scale, but holding off adding scheduled/ basal insulin while adjusting his enteral nutrition. Prophylaxis/ Lines and Tubes GI prophylaxis DVT prophylaxis Location/ date of invasive lines and tubes Patient is on IV PPI for ulcer prophylaxis, on enoxaparin BID. PICC RUE, day 10. Foley, day 5. Helpful hints: - Be succinct and synthesize the data. Have all the information available if asked, but don’t report every single bit of data. - Some problems can be relevant to multiple systems. For example, ventilator-associated pneumonia is related to the pulmonary system but overlaps with infectious disease. You can pick one system to discuss it, but you can also briefly mention it in the other relevant system. For example: Pulmonary- patient remains intubated, on antibiotics day x of x for VAP, CXR worsening/ stable, secretions improving. Then, later: ID- patient is on antibiotics day x of x for UTI, and day x of x for VAP. - If the patient’s BMP is normal, you can state that instead of reading every value. If there is one lab value that is abnormal but the remainder is normal, you can say “normal except for [elevated potassium of 5.5]” - Be thoughtful about ordering labs and imaging. Daily CXR purely because a patient is intubated for a bad TBI is not necessarily helpful. Even if the patient is being treated for pneumonia, daily CXR is unlikely to change your management unless there is a clinical change. CXR is appropriate if there are specific interventions that were performed or if the patient has a clinical deterioration- for example, following placement of chest tube for pleural effusion, following 24 hours of aggressive diuresis, for evaluation of acute dyspnea/ hypoxia. - Don’t repeat information presented by other team members- if the nurse has already provided infusion rates or RT has already provided ventilator settings, just move through the next part of the presentation. ICU Rounds .pdf Download PDF • 46KB A-F Bundle .pdf Download PDF • 33KB 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 Chronic Upper Abdominal Pain A 65-year-old female with chronic non-specific abdominal pain develops acute severe pain in her epigastrium. She presents to the ED for evaluation. What's on the differential diagnosis? Perforated hollow viscus Gastritis Peptic ulcer disease Pancreatitis Biliary pathology- cholecystitis, choledocholithiasis, hepatitis Pneumonia Myocardial ischemia What are the relevant clinical questions and what is included in a focused physical exam? Further details about the abdominal pain- prior similar episodes, onset/ duration, aggravating/ alleviating factors, constant or intermittent, radiating pain, severity, quality of pain (burning, stabbing, cramps). Associated symptoms- systemic symptoms. Fevers/ chills. Nausea/ vomiting. Change in color of urine or stool? Any prior medical or surgical history? Any medications? Smoker? Exam- abdominal palpation- identify tenderness and presence of peritonitis. The pain is stabbing and constant, and she's never had this pain before. She occasionally has right shoulder pain. She reports nausea and loss of appetite, but denies fevers/ chills/ vomiting. She had tea-colored urine and pale white stool a couple days ago. She has no medical or surgical history and is a non-smoker. On exam, she is afebrile, heart rate in the 90s. She is tender in the right upper quadrant with minimal palpation. What is the initial diagnostic workup? Labs: CBC, amylase/ lipase, hepatic enzymes, bilirubin Right upper quadrant ultrasound Possible computed tomography What ultrasound findings are consistent with cholelithiasis? Masses in the gallbladder that are echogenic (reflect on the anterior surface) with a posterior shadow and mobile/ dependent (move with changes in patient position). What ultrasound findings are consistent with acute calculous cholecystitis? Gallstones + gallbladder wall thickening + pericholecystic fluid +/- positive sonographic Murphys sign. What radiographic and laboratory findings are consistent with choledocholithiasis? Dilated common bile duct, stones visualized in the common bile duct, elevated bilirubin. What clinical/ radiologic/ laboratory findings are consistent with acute calculous cholecystitis? Criteria are based on Tokyo guidelines.[1] Local signs of inflammation- Murphy’s sign, RUQ mass/pain/tenderness Systemic signs of inflammation- fever, elevated CRP, elevated WBC count Imaging findings characteristic of acute cholecystitis Suspected diagnosis- one local sign + one systemic sign Definite diagnosis- one local sign + one systemic sign + imaging findings An ultrasound reveals gallstones, gallbladder wall thickening, and a dilated common bile duct. Her bilirubin is 2. Diagnosis? Cholecystitis with high risk for choledocholithiasis. Right Upper Quadrant Ultrasound- Gallstones Case courtesy of Maulik S Patel, Radiopaedia.org . From the case rID: 20542 Right Upper Quadrant Ultrasound- Gallbladder Wall Thickening Case courtesy of RMH Core Conditions, Radiopaedia.org . From the case rID: 3802 Patient was taken to the OR and underwent uncomplicated laparoscopic cholecystectomy. Intraoperative cholangiogram revealed multiple stones in the distal common bile duct. Despite multiple attempts, stone retrieval was unsuccessful. She underwent a postoperative endoscopic retrograde cholangiopancreatography (ERCP) with successful stone extraction. SAGES Guidelines on Diagnosis and Management of Choledocholithiasis Cholelithiasis, Predicting Likelihood of Choledocholithiasis Choledocholithiasis Management Algorithm Evaluation and Management of Acute Cholecystitis Diagnosis History- right upper quadrant/ epigastric pain, nausea/ vomiting. Labs- CBC, renal panel, LFTs. Radiology- right upper quadrant ultrasound. - Cholelithiasis: echogenic masses in the gallbladder with a posterior shadow that are mobile (move with changes in patient position). - Acute calculous cholecystitis: gallstones + gallbladder wall thickening + pericholecystic fluid +/- positive sonographic Murphys sign. Diagnostic Criteria for Acute Cholecystitis- Tokyo 2018 Guidelines[1] Local signs of inflammation- Murphy’s sign, RUQ mass/pain/tenderness Systemic signs of inflammation- fever, elevated CRP, elevated WBC count Imaging findings characteristic of acute cholecystitis Suspected diagnosis- one local sign + one systemic sign Definite diagnosis - one local sign + one systemic sign + imaging findings Management Cholecystitis is managed with early laparoscopic cholecystectomy unless the patient is too ill to tolerate surgery.[2] A percutaneous cholecystostomy is a minimally-invasive option for high-risk patients, avoiding the risk of general anesthesia. However, in a recent study of high-risk patients, cholecystectomy was associated with fewer complications than percutaneous cholecystostomy.[3] Evaluation and Management of Choledocholithiasis Diagnosis- dilated common bile duct, stones visualized in the common bile duct, elevated bilirubin. Management- common bile duct stones are managed with endoscopic or operative stone extraction.[4,5] References Yokoe M et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25(1):41-54. Okamoto K et al. Tokyo Guidelines 2018: Flowchart for the management of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25(1):55-72. Loozen CS et al. Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): multicentre randomised clinical trial. BMJ. 2018;363:k3965 . Manning A et al. Protocol-Driven Management of Suspected Common Duct Stones. J Am Coll Surg. 2017;224(4):645-649. Clinical Spotlight Review: Management of Choledocholithiasis - A SAGES Publication. SAGES. Accessed July 13, 2022. Previous Next

Places to Go, Things to Do Bucket List Places to Go, Things to Do Places I Want to Visit The Narrows- Zion National Park Apostle Islands National Lakeshore Spain (went as a kid, want to go back) √ Grand Canyon Mexico Alaska Europe Machu Picchu (Peru) Australia Hawaii √ Adventures I want to Experience Watch a Bruins game at TD Gardens in Boston Hang-gliding Backcountry camping Snowboard in Canada and Europe Horseback ride on the beach Eat at a Michelin 3-star Restaurant Things I Want to Accomplish Donate blood √ Become fluent in Spanish Start a charity Own a house in Boston Own a horse ranch Own a dog Publish something non-medical Fears to Overcome Speak in front of a large audience (EAST conference, AAST conference) √ Experiences I don't care to repeat, but glad I did them once Tough Mudder Eaten alligator and shark Things others want to do that I have no desire to do Skydiving Scuba diving Attend the Masters Previous Next

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

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

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

< Back Pulmonary Embolism...pending Diagnosis and Treatment of Pulmonary Embolism Previous Next

< Back Hemorrhoids What are hemorrhoids? Patient information: Hemorrhoids [American College of Colon and Rectal Surgeons] Patient education: Hemorrhoids (Beyond the Basics) [UpToDate] Hemorrhoids are a normal part of anorectal anatomy. They are blood vessels in the end of the rectum and at the anal verge. External hemorrhoids overlie the external anal sphincter (at the anal verge) and the internal hemorrhoids overlie the internal anal sphincter (inside the rectum). The hemorrhoids fill with blood and help maintain continence (avoid leaking stool). See images below. Anything that increases pressure in the abdomen, including prolonged straining, coughing, pregnancy, and an enlarged prostate requiring straining to urinate, can lead to abnormally large venous plexuses, which are what most people know as hemorrhoids. Internal hemorrhoids are lined by the same tissue as the rest of the GI tract, which secretes mucus. External hemorrhoids are lined by the same tissue as the rest of the skin on our bodies. Source: UpToDate Images: Internal and External Hemorrhoids Symptoms When hemorrhoids become abnormally large as a result of prolonged straining, typically from constipation, they can cause pain and bleeding. Internal hemorrhoids- dull/ achy pain and bleeding with bowel movements. In addition, if internal hemorrhoids prolapse (move from inside the rectum out onto the perianal skin), which typically occurs with bowel movements, this can cause issues with perianal moisture, itching and skin irritation. This is caused by the mucus from the overlying tissue. Prolapsed hemorrhoids can sometimes reduce spontaneously (return to their normal location in the rectum) or might require manual reduction (might have to be pushed back in after having a bowel movement). If internal hemorrhoids External hemorrhoids- bleeding with bowel movements. Acute pain can occur when an external hemorrhoid becomes thrombosed (acutely filled with blood clot→ overlying skin gets stretched→ severe pain). What is conservative management for hemorrhoids? See “ Anorectal Disease: How do I prevent anorectal disease? ” Improving bowel habits is the first-line treatment for hemorrhoids. See patient handouts below. 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. For itching: moisture in the perianal skin can cause itching. Improving bowel habits and gentle perianal skin hygiene can improve this. Zinc oxide can be used as a topical barrier twice daily. For protruding or swollen internal hemorrhoids: hold the hemorrhoid tissue with a Tucks pads (witch hazel) to decrease the swelling, allowing the hemorrhoid tissue to be reduced. Patient Info- Hemorrhoids .pdf Download PDF • 58KB Patient Info- Fiber Guide .pdf Download PDF • 68KB What is the operative management of hemorrhoids? Acute thrombosis of external hemorrhoids- most patients will have resolution of symptoms with conservative management described above. However, if you present within the first 48-72 hours, the hemorrhoid can be excised. Incision and drainage alone is not recommended, given high rates of recurrence. If symptoms have been present for more than 72 hours, surgery is more likely to create more discomfort, and therefore it is typically avoided. Large external hemorrhoids or mixed internal and external hemorrhoids with prolapse- typically managed with hemorrhoidectomy or hemorrhoidopexy. Internal hemorrhoids- banding is the most common treatment. Other options include sclerotherapy and infrared coagulation. Previous Next