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< Back Postoperative hypotension A 35-year-old male is in the ICU following emergency surgery for a small bowel obstruction. On arrival to the ICU, he has the following vital signs: HR 115, BP 85/40, SpO2 98. He underwent a 4-hour open lysis of adhesions. He received 2L of crystalloid and made 50 mL of dark urine, and did not require any medication to improve his blood pressure. He remains intubated and sedated. What is the differential for his hypotension? Hypovolemia- under-resuscitation relative to the insensible losses from open abdomen and likely preoperative dehydration Sepsis- bacteremia from gut translocation from small bowel obstruction, pneumonia from aspiration due to obstruction Tamponade, tension pneumothorax- did he have any intra-vascular devices placed in the OR? Pulmonary embolism- lengthy surgery, did he have appropriate mechanical prophylaxis? Cardiomyopathy The surgical team reports that he has not been tolerating a diet, or even liquids, for the previous 3 days. He received perioperative ertapenem for surgical infection prophylaxis. There was no evidence of aspiration during intubation and his admission CXR was unremarkable. He had a right internal jugular central line placed intra-operatively. He had no issues with oxygenation/ ventilation or high airway pressures intra-operatively. How can you diagnose shock and differentiate between the different potential etiologies? Physical exam- evaluation of skin turgor/ color/ temperature and mucous membranes, evaluation of fluid status (open wounds, nasogastric tube output, passive leg raise), examination of urine quality, auscultation of heart/ lungs Labs- cultures, complete blood count, lactate, liver function tests, BUN/Cr Ultrasound- gross evaluation of heart function, lung sliding to rule out pneumothorax, volume and collapsibility of the inferior vena cava Test for fluid responsiveness- based on stroke volume variation (SVV, see below), or response to passive leg raise or a fluid challenge. On exam, he is tachycardic without murmurs, lungs have equal air movement bilaterally. His nasogastric tube remains on suction with ongoing high output of gastric contents. On ultrasound, he has bilateral lung sliding. His cardiac contractility looks grossly preserved. He has normal oxygenation. His inferior vena cava is collapsible. He has a known source of infection (positive blood cultures), leukocytosis, elevated lactate, high fluid losses with evidence of fluid responsiveness. Shock: Undifferentiated Hypotension Hypotension ≠ shock. So what is shock? Inadequate perfusion to maintain end-organ function Pathophysiology: effective perfusion requires adequate cardiac output (CO). CO is the volume of blood that the heart pumps each minute, and it depends on stroke volume (SV; the volume of blood ejected with each heartbeat) and heart rate (HR; the number of heartbeats per minute). SV depends on preload (intra-vascular volume returning to the heart), myocardial contractility, and afterload (systemic vascular resistance). Shock is a disruption of preload, contractility, and/ or afterload. Signs of shock= signs of end-organ hypoperfusion Altered mental status (brain) Decreased urine output (kidney) Change in color/ temperature of extremities (skin) Abnormal liver function tests (liver) Ileus (gastrointestinal tract) Diagnosis of shock + tools for monitoring response to treatment Elevated lactate (global hypoperfusion) Ultrasound- evaluate cardiac function, evaluated IVC to assess volume status Minimally invasive cardiac monitoring (central line or arterial line)- CVP and SVV to assess volume status Invasive cardiac monitoring (pulmonary artery catheter)- cardiac output, ScVO2 (central venous oxygen saturation) Four types of shock Shock is typically categorized as hypovolemic, obstructive, cardiogenic or distributive. However, in order to link the specific category with the associated pathophysiology, I have described each state as it relates to maintaining cardiac output, as described above. Decreased preload: hypovolemic shock- low circulating blood volume→ decreased blood volume returning to the heart. Etiologies: bleeding, inadequate fluid replacement/ maintenance, high output from nasogastric tube or ostomy, insensible losses that aren't appropriately replaced (burn patients, large open wounds). Decreased preload: obstructive shock- disease process that impedes venous return to the heart (tamponade, tension pneumothorax, pulmonary embolism). Decreased contractility: cardiogenic shock- disturbance of the intrinsic function of the heart. Etiologies: heart failure, arrhythmias, valvular insufficiency, or decompensated valvular stenosis. Decreased afterload: distributive shock- dilated peripheral vasculature, sometimes known as vasoplegia. Etiologies: sepsis, anaphylaxis, neurogenic following spinal cord injury (NOTE- this is NOT the same as spinal shock), burns, trauma, pancreatitis. Neurogenic- hypotension with concurrent bradycardia. Vasoplegia is a term used to describe pathologically low systemic vascular resistance- this can be associated with post-cardiac bypass or any of the other causes mentioned here. Management of shock Treat underlying cause (see below). Restore adequate intravascular volume (aka preload). This is part of the initial treatment of hypovolemic shock, obstructive shock, and distributive shock. Fluids in the management of cardiogenic shock depend on the primary cardiac pathology. Treat hypotension/ decreased cardiac output that persists despite fluid resuscitation and treatment of the underlying cause. Septic shock- norepinephrine is the first line vasoactive medication. Monitor end-points of resuscitation (see above, Diagnosis of shock + tools for monitoring response to treatment ) Supportive care- nutrition, respiratory support, venous thromboembolism, etc. Specific Treatments Based on Etiology Hypovolemia from hemorrhage- transfusion, stop the bleeding Hypovolemia from fluid losses- replace fluid via enteral or intravenous route, as appropriate Sepsis- antibiotics, control source of infection (appendectomy, drain placement, etc). Tamponade- drainage of pericardial fluid (pericardiocentesis, pericardial window) Tension pneumothorax- release of tension physiology (needle decompression or finger thoracostomy) Cardiogenic- management of primary cardiac pathology, whether that entails treating acutely decompensated heart failure, resolving acute symptomatic arrhythmias, etc. Previous Next

< Back Colorectal Disease UpToDate Patient Education Patient education: Diverticular disease (Beyond the Basics) . Also known as diverticulosis. If associated with an acute episode of infection, this is reference to as diverticulitis. Patient education: Constipation in adults (Beyond the Basics) Patient education: High-fiber diet (Beyond the Basics) Patient education: Colonoscopy (Beyond the Basics) Patient Information from Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Colonoscopy American College of Surgeons: Division of Education Colonoscopy Prep Form Golytely®, Colyte®, Nulytely®, Trilyte® Source: UpToDate Images: Colon and Rectum Patient Info- Constipation .pdf Download PDF • 54KB Previous Next

< Back Diverticulitis...pending A 52-year-old female developed left lower quadrant abdominal pain, which she thought it was gas pain or indigestion. Unfortunately, the pain worsened and became so severe that she presented to the ER for evaluation. Associated symptoms include nausea, vomiting, lower grade fever and constipation. CBC revealed WBC of 13.5, renal panel was unremarkable. A CT of the abdomen/ pelvis with oral and IV contrast was obtained. CT Scan of Diverticulitis There was minimal thickening and inflammatory changes in the sigmoid colon. She was diagnosed with diverticulitis and discharged with a course of oral antibiotics. Over the next several months, she continued to have pain, with increasingly frequent and intense episodes. She was admitted to the surgery service several months later for a particularly severe episode. She was treated with IV antibiotics and then had resolution of her symptoms and was discharged home. What is the next step? Schedule for colonoscopy to rule underlying pathology. Discuss elective sigmoid colectomy for recurrent episodes of diverticulitis. The plan was to schedule a colonoscopy, but unfortunately, she never had a symptom-free interval. She returned several days later with recurrent pain. She was presented with the option of surgical intervention to remove the inflamed part of her colon. She underwent an uncomplicated laparoscopic sigmoid colectomy with primary anastomosis. Management of Diverticulitis Previously, antibiotics were recommended for the management of diverticulitis, regardless of severity. Two studies (AVOD, DIABOLO) have demonstrated no difference in outcomes for patients with uncomplicated diverticulitis that were managed with or without antibiotics.[1,2] Patients who have an episode of complicated diverticulitis (episode associated with free colon perforation, fistula, abscess, stricture, or obstruction) require an endoscopy to evaluate for underlying malignancy. Indications for Surgery Emergent surgery- acute episode with perforation or peritonitis. Semi-urgent surgery- failure of non-operative management (ie symptoms persist despite bowel rest and antibiotics). Elective colectomy - Resolved episode of diverticulitis associated with abscess/ fistula/ stricture/ obstruction. - Recurrent episodes of uncomplicated diverticulitis that interfere with the patient's lifestyle (frequent episodes, repeated hospital admissions, etc). For More Information on the Management of Diverticulitis ASCRS Patient Information: Diverticular Disease AVOD Trial. Chabok A et al; AVOD Study Group. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg. 2012;99:532–539 . Diabolo Trial. Daniels L et al; Dutch Diverticular Disease (3D) Collaborative Study Group. Randomized clinical trial of observational versus antibiotic treatment for a first episode of CT-proven uncomplicated acute diverticulitis. Br J Surg. 2017;104:52–61. Previous Next

Give me that thing that does the thing… Kelly Snap Mosquito < Back Give me that thing that does the thing… I don’t remember the names of all the instruments in the surgical tray. I swear they have a unique name for each size of the same instrument. Hemostats- crile, snap, stat, mosquito, tonsil, Kelly, Rochester Pean. There is a laundry list of pickups of different shapes with different teeth. And then throw in the culture of different hospitals and specialties. When you place a Bookwalter and you want the short wide curved retractor…do you call it a bladder blade or a curved body wall? And the straight one…is that a Rich or a body wall? In case you’re wondering, the curved retractor is called a Balfour and the straight retractor is called a Kelly. When you’re doing a laparoscopic cholecystectomy, do you ever ask for a wavy grasper or do you call it a prestige? Or something else altogether? As I resident and attending, I used a wavy grasper . Check out the picture. Doesn’t it look like…a wavy? When I was in fellowship, the same instrument was called a prestige. Sounds unnecessarily boastful to me, but whatever. After 9 years using a wavy, it was hard to break the habit and call it a prestige. Thankfully, the scrubs knew what I wanted. I found out it's actually called a Prestige Style Atraumatic Wavy Grasper , so it turns out, we are both right. But that would take way too long to say each time you want to grasp the infundibulum. As we move through training, we develop routines, including our favorite instruments to use during different steps of the operation. When surgeons and scrub techs spend time together during cases, they frequently develop a rhythm, a shorthand. A good scrub tech knows what you want before you even ask. I have had the fortunate of developing several relationships like this. My favorite scrub tech was Kelly. She was a fantastic tech, but also a fantastic person. And the joke of asking for Kelly Kelly never got old. After years of working together, she understood my style and my technique, and always had my next instrument ready. To be honest, it didn’t take years. She knew what I wanted, even if I asked for the wrong thing. She was an invaluable asset to the team, and I miss working in the OR with her. As I mentioned, I don’t remember the names of all the instruments in the surgical tray. A good scrub tech gives you what you want, not what you ask for. While operating, I often extend my hand toward my scrub tech, and as I’m trying to come up with the right name, I start to make gestures with my fingers. Fingers posed like holding a pencil signals scalpel. Thumb and index finger pinched together is my gesture for pickups. Index and middle finger in an open/close motion indicate scissors. Curved fingers, like holding a cup, means I want a retractor. And I request a needle driver by holding the scalpel pose and moving my wrist through a suturing motion. There have been many innovations brought about by the COVID pandemic, and I predict that business will never be conducted the same as before this era. The protective gear worn to prevent viral transmission negatively impacts team communication. This was one of the summary findings of a survey of surgeons, recently published in the World Journal of Surgery.(1) The impact on speech discrimination has been quantified in an experiment with a simulated noisy background.(2) Google “communication impediment COVID protective equipment” and you will encounter many publications regarding the unintended consequences of interventions designed to keep health care personnel safer. Before the pandemic, we already operated wearing masks, which eliminates some of the visual cues of communication. But novel respirators can add several hindrances, including restricting normal jaw movement and muffling the spoken word. The use of the PAPR (powered air-purifying respirator) added a whole new dimension- noise from the fan and battery adds a remarkable hurdle when the surgical team is trying to communicate with other members of the operating team. Admittedly my system is imperfect, and I think a universal sign language for the operating room is a brilliant concept. A proposed system was recently published in the British Journal of Surgery.(3) Signals were developed to request a scalpel, various retractors, forceps, needle drivers, and gauze. This concept is logical, although admittedly, I have become increasingly reticent to accept any innovation just because it appears simple and absent of downsides. Consider the intubation boxes that were developed to prevent aerosol dissemination early in the pandemic. The concept was rational- solid barrier to isolate the patient, great idea! But during simulation, there were multiple hurdles- largely, it makes difficult intubation more challenging, which potentially defeats the purpose by increasing maneuvers and personnel and time to successful intubation. To quote one review: “Well-designed simulations…should always be used to test medical innovations before implementation... “Face validity” alone should not be the basis of innovation adoption.”(4) Is a new language necessary? Do we really need a system to talk to the tech, who is standing closer to us than anyone else in the room, and probably already knows what we want? They are more focused on exactly what is going on in the operative field than anyone else, and they can lean closer or ask us to repeat our request. We need a better way to talk to everyone else in the room! The anesthesiologist who is balancing multiple tasks and the OR nurse who is at least several steps away from the surgeon. What are the potential roadblocks or negative consequences associated with implementation? · Potential for misinterpretation of signals…someone is expecting a pickup and they’re handed a scalpel, which is quickly brought into the field and creates an injury. · The inability of the surgeon to create the signal if both hands are working. · If verbal communication is eliminated, the tech has to constantly watch the surgeons hands, which prevents them from doing other manual tasks, such as loading clip appliers, returning needles to the count box, receiving freshly opened materials from the scrub nurse, etc After all that, I’m not rendering a final verdict. This is an innovative and intriguing concept with a lot of potential. It should be considered and trialed while ensuring that its benefits outweigh the negative impacts before wide-spread implementation. 1. Yánez Benítez C et al. Impact of Personal Protective Equipment on Surgical Performance During the COVID-19 Pandemic. World J Surg. 2020 Sep;44(9):2842-2847 . 2. Hampton T et al. The negative impact of wearing personal protective equipment on communication during coronavirus disease 2019. J Laryngol Otol. 2020 Jul;134(7):577-581 . 3. Leyva-Moraga FA et al. Effective surgical communication during the COVID-19 pandemic: sign language. Br J Surg. 2020;107(10):e429-430 4. Chan A. Should we use an “aerosol box” for intubation? Life in the Fast Lane. 2020 Jul. https://litfl.com/should-we-use-an-aerosol-box-for-intubation/ Previous Next

< Back Vent Mgmt #2: Modes Mandatory Breaths Volume control (volume limited)- set TV and flow, pressure and inspiratory time are the dependent variables. Pressure control (pressure limited)- set inspiratory pressure and inspiratory time, volume and flow are the dependent variables. What is the downside of VC and PC? You can only control one parameter, and the dependent variable varies based on the patient's lung mechanics. For a patient on VC, if their lungs become less compliant, delivering the same tidal volume will generate higher pressure, increasing the risk of barotrauma. For a patient on PC, if their lungs become less compliant, the target pressure will be reached at a lower volume, so there is a risk of decreased ventilation (↑PaCO2). Pressure-regulated volume control (PRVC) is a hybrid mode that attempts to overcome this limitation. The target volume is delivered at the lowest possible inspiratory pressure by assessing the delivered tidal volume at the inspiratory pressure during each breath. What about inverse ratio (IR, IRV-PC) ? Increasing the inspiratory time relative to expiratory time increases mean airway pressure. This can be accomplished with pressure-controlled modes, where inspiratory time can be prolonged (normal ratio 1:2, IRV is when inspiratory time is greater than expiratory time). As discussed, MAP affects the surface available for oxygen exchange. This is why IR can be used to optimize oxygenation. Mandatory and Spontaneous Breaths Synchronized intermittent mandatory ventilation (SIMV)- a variation on VC or PC. The machine delivers mandatory breaths, but the patient can also control spontaneous breaths in between the mandatory breaths. Spontaneous Breaths Pressure support- spontaneous mode, the patient initiates breath, the ventilator provides support to overcome the resistance of breathing through the endotracheal tube, flow is adjusted to maintain the inspiratory pressure. The support is terminated when the flow decreases to <25% of peak flow. The patient controls duration and volume. *This is also a setting that can be adjusted in SIMV for assisting spontaneous breaths between ventilator breaths. Airway Pressure Release Ventilation (APRV)- invasive form of ventilation with BiPAP. The patient breaths spontaneously, alternating between a sustained time (time-high) at a set pressure (pressure-high) with a very brief release (time-low) of pressure (pressure low) to allow expiration. The goal is to maintain a higher MAP to optimize oxygenation. Previous Next

< Back Intracranial Hypertension A 32-year-old male was an unhelmeted motorcyclist who was struck by a car and throw 20 feet. He had decreased alertness on the scene and was urgently transported to the hospital. On arrival to the ED, his GCS was 7 (E2V2M3). He was hemodynamically normal and secondary survey was only remarkable for diffuse road rash and a large scalp laceration. He was intubated for concern for inadequate airway protection. Chest x-ray revealed multiple left sided rib fractures, FAST was positive in the right upper quadrant and the pelvis x-ray was unremarkable. He was taken to the CT scanner for head, c-spine, chest, abdomen and pelvis imaging. He was transported to the trauma ICU as his images were reviewed. Head CT Case courtesy of Derek Smith. From the case rID: 169704. Imaging revealed a large right sided subdural hematoma. He has left lower rib fractures and a grade 3 splenic injury. Neurosurgery evaluated him upon arrival to the ICU. How is intracranial pressure monitored? The preferred method for ICP monitoring is with an external ventricular drain. This allows the dual function of monitoring ICP as well as allowing to treatment of elevated ICP via drainage of cerebrospinal fluid (CSF). What is a normal value for ICP? Normal ICP is <20 mmHg and treatment is recommended for sustained ICP >22 mmHg. Neurosurgery places an external ventricular drain. His opening pressure was 32, and his ICP ranges from 25-32 over the next few hours. He was in reverse Trendelenburg, and he was adequately sedated. His repeat head CT was unchanged. He had CSF drainage via his EVD. He was given 2 boluses of hypertonic saline. His ICPs improved, and were sustained at 18-20 mmHg. He develops hypotension, with systolic pressures in the 80s. What are some of the possible etiologies for hypotension, and how would you evaluate/ treat the various etiologies? Bleeding from his spleen→ urgent splenectomy. Hypotension is detrimental to TBI. Side effects from sedation medication→ decrease dosages or switch therapeutic agents, implement other treatment strategies Evaluation and Management of Traumatic Brain Injury The goal of the initial management of TBI is the prevention of secondary brain injury. Avoid hypotension and hypoxemia Target normal pulse oximetry, normal PaCO2 (35-45 mmHg) and PaO2 (≥100 mmHg), normal blood pressure (SBP ≥100), normal electrolytes, normal temperature, platelets >75K, hemoglobin >7 g/dL.[1] Treat pain and provide sedation as appropriate. Optimize patient positioning to promote cerebral venous drainage- elevate the head of the bed and ensure the cervical collar or endotracheal tube support is not too tight. Monro-Kellie Doctrine[2] Inside the bony skull, there is brain tissue, blood and cerebrospinal fluid. Increase in any one of these (tumor, hemorrhage, edema) requires a compensatory decrease in one of the other substances in order to maintain normal intracranial pressure (ICP). ICP rises when compensatory mechanisms fail. Elevated ICP leads to decreased cerebral perfusion pressure (CPP). CPP is the difference between mean arterial pressure and intracranial pressure, and serves as an additional measure of adequacy of cerebral perfusion [CPP= MAP – ICP]. This is similar to the concept of abdominal compartment syndrome- when intraabdominal pressure increases above a threshold, there is decreased organ perfusion. Initially, the brain is able to autoregulate and maintain cerebral blood flow (CBF) across a narrow range of CPP, but this compensation is also limited, and CBF decreases as CPP falls. The general target for CPP is ≥60 mmHg, but note that this may vary if cerebral blood flow autoregulation is impaired. Monitoring intracranial pressure (ICP) is not independently associated with improved outcomes. It does not replace serial neurologic exams. Clinical decision making based on the neurologic exam, the ICP, CT imaging and any other relevant information is the key to improving outcomes. There are several patient scenarios that should prompt consideration of ICP monitoring.[1,3] GCS ≤8 + structural brain injury on head CT GCS >8 + structural brain injury on head CT + high risk for progression (large/ multiple contusions, coagulopathy Severe TBI with a normal CT scan + at least 2 of the following- age >40 years, unilateral or bilateral motor posturing, or SBP <90 mm Hg. Progression of brain injury on repeat CT imaging Patients who require urgent surgery for extracranial injuries Clinical deterioration There is a tiered approach to treating elevated ICP.[1] At each tier, patients should continue to have close neurologic exams as well as interval repeat CT imaging of the head to rule-out the progression of hemorrhage. Tier 1- ensure optimization of analgesia and sedation, elevate head of bed, intermittent drainage of CSF. Tier 2- hyperosmolar therapy- mannitol or hypertonic saline. Consider advanced monitoring, including assessment of cerebral autoregulation and other markers of cerebral oxygenation. If utilizing advanced monitoring, consider hyperventilation to PaCO2 30-35 as long as cerebral oxygenation is maintained. Paralysis with neuromuscular blockade. Tier 3- decompressive craniectomy is a potential salvage therapy- may be associated with decreased mortality, but no improvement in neurologic outcomes.[4,5] Continuous infusion of neuromuscular blockade if there is a response to the test dose in Tier 2. Consider Barbiturate coma. Hypothermia and hyperventilation are no longer routinely recommended. Hyperventilation therapy can be used as a bridge to additional interventions. A study of hypothermia in severe TBI has shown no improvement in early neurologic outcome.[6] References ACS Committee on Trauma. American College of Surgeons Trauma Quality Improvement Program. Best Practices in the Management of Traumatic Brain Injury. 2015 Jan. Wells AJ et al. The management of traumatic brain injury. Surgery (Oxford). 2021;39(8):470-478. Carney N et al. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery. 2017 Jan 1;80(1):6-15. Cooper DJ et al. Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med. 2011 Apr 21;364(16):1493-502. Cooper JD et al. Effect of Early Sustained Prophylactic Hypothermia on Neurologic Outcomes Among Patients With Severe Traumatic Brain Injury: The POLAR Randomized Clinical Trial. JAMA. 2018;320(21):2211-2220 Sahuquillo J, Dennis JA. Decompressive craniectomy for the treatment of high intracranial pressure in closed traumatic brain injury. Cochrane Database Syst Rev. 2019 Dec 31;12(12):CD003983 Previous Next

Stereotype of a Surgeon Heartless with a God Complex < Back Stereotype of a Surgeon Abrasive, intimidating, self-confident, egotistic, stubborn, arrogant, difficult to work with, aggressive, competitive, and domineering, technically masterful, astute, energetic, and precise.(1) These are just a few of the adjectives that have been used to describe surgeons. The top Google autocompletes for the phrase "why are surgeons…” include arrogant, rough, rude, important, jerks, mean, cold, weird. There is a balancing act between the need to demonstrate confidence while maintaining our humanity and our humility. We wield sharp instruments, and we ask our patients to trust us to fix them while they lay naked and exposed, anesthetized, and vulnerable. So how do we reconcile these seemingly opposing characteristics? How do we show strength, leadership, and confidence in our decision-making and skills and also develop a rapport with patients and families? How do we show our patients that we will be with them to celebrate their recovery and stand by them in the face of complications and setbacks in their recovery? Effective communication is key to relationship building. In general, surgeons are not known for their stereotype that surgeons don't have the best bedside manner. "As a group, surgeons are not well known for their bedside manner."(2) We (usually) operate on completely unresponsive patients, so the stereotype that we don’t like talking to patients is not illogical. This stereotype extends to anesthesiologists. While this is a satirical representation, there is a kernel of truth in the idea that most don’t go into specialties that frequent the OR to spend MORE time talking to patients. "While poor manners aren't commonly accepted in most professional circles, representations of surgeons in popular culture often link technical prowess with rude behavior, and some surgeons have even argued that insensitivity can be helpful in such an emotionally strenuous profession."(2) I probably spend more time talking to patients and their families than the typical surgeon. I find these personal interactions to be truly remarkable. During my training, I developed my style for communication. When I share information with a patient and their family, I treat them as if it were my family member. Based on my perception of their interest in detail and my direct explanation that I will share as much or as little as they like, I tailor my interaction with each new encounter. I believe in full disclosure, including admitting when I don’t have the answers. My training has given me the confidence to admit when I need more information or plan to consult with a colleague. Some might see my willingness to admit imperfections as a sign of weakness. While I didn’t develop my practice regarding disclosure with the express intention of avoiding legal consequences, poor communication and lack of empathy are commonly cited in malpractice suits.(3) So besides the intrinsic benefit of developing respectful interactions with patients, the extrinsic factor of avoiding the courtroom is powerful. A study published in 2019 found that surgeons are regarded as high in warmth and competence, relative to other non-medical occupational groups,(4) in contrast with the stereotype that we lack social skills. The study also noted that female surgeons received higher warmth ratings than male surgeons, while male surgeons received higher competence ratings than female surgeons. It is not an easy task, but building trust with our patients requires us to instill confidence while maintaining our humanity. 1. Logghe HJ. History of Medicine: The Evolving Surgeon Image. AMA J Ethics. 2018;20(5):492-500. 2. Neilson S. When Surgeons Are Abrasive To Co-Workers, Patients' Health May Suffer. 2019 Jun. NPR. 3. Huntington B. Communication gaffes: a root cause of malpractice claims. BUMC Proceeding. 2003;16:157–161. 4. Ashton-James CE. Stereotypes about surgeon warmth and competence: The role of surgeon gender. PLoS ONE 14(2): e0211890. Previous Next

< Back Sausage Tortellini and Brussels Sprouts Ingredients Sausage Tortellini 2 Tbsp olive oil 2 lbs sausage 2 cloves garlic, minced 1 c vegetable broth 2 c tomato sauce ½ c heavy cream 18 oz tortellini Salt & pepper Brussels Sprouts One package of Brussels Sprouts olive oil black pepper sea salt balsamic vinegar Instructions Sausage Tortellini Heat oil in a large skillet and cook sausage links about 5-7 minutes, until sausages are browned throughout. Add garlic and heat for 30 seconds. Remove sausages from skillet and slice into bite-size pieces. Return sausages to pan along with broth, tomato sauce, cream, and tortellini. Season with salt & pepper. Cover and simmer for 12 minutes. Brussels Sprouts Prepare sprouts by trimming the base and then cutting the sprouts in half or quarters, and then place them in a medium-sized bowl. Drizzle a small amount of olive oil and balsalmic vinegar, and then sprinkle black pepper and sea salt. Toss to coat the sprouts, let sit for at least 30 min. Roast at 400 for 20-30 min, toss halfway through. Sausages cooking Previous Tortellini in Sauce Brussels Sprouts Next

Confessions of an ICU Physician with a terrible memory Accessing the Right Information < Back Confessions of an ICU Physician with a terrible memory Training in medicine starts with textbook learning. But the art of caring for patients can’t be learned in a textbook. Higher-order thinking is essential to understand the interaction between multiple conflicting disease processes, identify nuisances of atypical presentations and find solutions for clinical conundrums. As the field of medicine grows exponentially, the volume of information is too much for one person to keep track of. I find that understanding clinical concepts is much easier than rote memorization of pharmaceutical brand names with their associated generic name, recalling the dose of a paralytic, or identifying the ideal antibiotic for a multi-drug resistant bacteria. After several years of learning and studying mechanical ventilation and how it interacts with and affects a patient's respiratory physiology, I now understand the principles of how to optimize oxygenation and ventilation. As an ICU physician, I can't re-read the basic textbook of mechanical ventilation every time I care for a patient with respiratory failure. I must be able to make decisions relatively quickly and must be able to explain my rationale to residents and bedside nurses while we are working to manage a patient with severe lung disease. But I can pause to look up the recommended dosing of a medication for a patient on dialysis or identify the best anti-microbial for a particular bacteria or fungi. What do I do about important information that I need immediate access to but that doesn't reside in the forefront of my mind? Smartphones, with access to websites and applications , have revolutionized our ability to bring evidence-based medicine to the bedside. Clinical practice guidelines can be accessed on society websites. Deployed Medicine is a resource that provides access to Tactical Combat Casualty Care and Joint Trauma System Clinical Practice Guidelines. There are apps for a wide number of clinical programs that were initially web-based, such as UpToDate. In addition to the resources that are openly available to the public, I have created a database of personal high-yield references. Medication dose ranges, CPGs for our trauma center, AAST Injury Scales, sedation/ pain scores, TEG parameters, and a wide variety of other information that I refer to on a relatively routine basis are now in the palm of my hand. I use the Trello app. I created a dedicated workspace with a group of lists (titles such as trauma, medication, ICU, etc) which each contain multiple individual cards (titles such as A-F bundle, CAM-ICU/ RASS/ CPOT, TEG). I'm not saying you have to use this. But I highly recommend finding a tool that works for you. TL;DR • Take the time to understand processes and concepts- learn one physiology concept from each pt • Have an external tool for storing “rote memorization” facts that you can readily access Previous Next

< Back Ultrasound: Just The Basics Ultrasound is a non-invasive, repeatable, portable, reproducible diagnostic tool. It can be used virtually anywhere that patient care is being performed, including pre-hospital, the ER, OR, ICU, and non-ICU inpatient wards. Ultrasound skills vary between providers. I am a strong advocate of utilizing the ultrasound, and you will become more comfortable as you increase your utilization of the US. The credentialing process for ACS surgeons is not well-established, and we do not have the same expertise as radiologists. SCCM guidelines currently support ICU providers' utilization of US for certain scenarios. However, ICU providers are not as reliable in certain diagnoses, such as biliary pathology. Basics of Ultrasound: How Does it Work? Crystal excited by electrical pulses (piezoelectric effect)→ mechanical oscillations→ sound waves emitted. Sound waves are reflected at interfaces of different acoustic densities. Higher acoustic density→ increased intensity of reflected sound and decreased transmission of remaining sound waves. If the interface is between objects of vastly different acoustic density→ complete sound wave reflects and total acoustic shadowing occurs (dark behind the object); examples include bone, stones, and air. Probe selection Linear array- parallel sound waves→ rectangular images. Near-field resolution, high frequencies 5-7.5 MHz)- good for thyroid and soft tissue. Artifact on curved surfaces. Not good for intra-thoracic or upper abdominal organs. Sector/ phased array- fan-like image (narrow nearest transducer and widening with deeper penetration). Frequency 2-3 MHz. Poor for near-field resolution. Used for cardiac imaging. Curved (convex) array- abdominal sonography. 3.5-3.75 MHz. Deeper tissue penetration. *Probe marker correlates with the dot on the screen to establish orientation. Artifacts Reverberation echoes-several strongly reflecting boundaries→ reflection of sound waves back and forth→ echoes (several parallel lines close to the transducer). A-lines when scanning the lung- hyperechoic arcs parallel to the pleural line. These are seen at intervals that are the same as the interval from the skin to the pleural line. Absence of A lines= change in attenuation coefficient of the lung (edema, consolidation). B-lines when scanning the lung (comet-tail artifact)- vertical hyperechoic lines, caused by fluid-filled intra-lobular or interlobular septa touching the visceral pleural surface. Distal acoustic enhancement- sound waves travel through homogenous fluid (low reflection)→ less sound wave attenuation, so they are more amplified compared to adjacent sound waves (because the structures they passed through reflected some of the waves). *Brightness (increased echogenicity) behind fluid-filled structures such as the bladder or gallbladder. Mirror image- diaphragm and visceral pleura→ intrahepatic structures can be seen on the pulmonary side of the diaphragm. Acoustic shadowing- interface between tissue and bone or tissue and air→ scattered beam→ inability to image deeper structures. Knobology Identify the probe Identify the selected study type (cardiac, FAST, soft tissue, etc) Gain- increases the strength of sound/ brightness of the visualized area Depth-gain compensation- selective enhancement of echoes received at different depths→ moving depth up or down increases or decreased the field of view. Time-gain compensation- adjust the strength of the beam to areas that would normally have attenuated beams. M-mode- display and measure movement of structures over time along a single lione (axis of the beam). Good for heart or valve motion (echo), hemodynamic status (respiratory change in IVC diameter) and lung sliding or diaphragm movement. Doppler- changes in frequency cause by reflections off a moving target (usually blood). References Frankel HL et al. Guidelines for the Appropriate Use of Bedside General and Cardiac Ultrasonography in the Evaluation of Critically Ill Patients-Part I: General Ultrasonography. Crit Care Med. 2015 Nov;43(11):2479-502. Levitov A et al. Guidelines for the Appropriate Use of Bedside General and Cardiac Ultrasonography in the Evaluation of Critically Ill Patients-Part II: Cardiac Ultrasonography. Crit Care Med. 2016 Jun;44(6):1206-27. Labovitz AJ et al. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. J Am Soc Echocardiogr. 2010 Dec;23(12):1225-30. Borloz MP et al. Emergency department focused bedside echocardiography in massive pulmonary embolism. J Emerg Med. 2011 Dec;41(6):658-60. Bakhru RN, Schweickert WD. Intensive care ultrasound: I. Physics, equipment, and image quality. Ann Am Thorac Soc. 2013 Oct;10(5):540-8. Silverberg MJ et al. Intensive care ultrasound: II. Central vascular access and venous diagnostic ultrasound. Ann Am Thorac Soc. 2013 Oct;10(5):549-56. Doerschug KC et al. Intensive care ultrasound: III. Lung and pleural ultrasound for the intensivist. Ann Am Thorac Soc. 2013 Dec;10(6):708-12. Boniface KS et al. Intensive care ultrasound: IV. Abdominal ultrasound in critical care. Ann Am Thorac Soc. 2013 Dec;10(6):713-24. Repessé X et al. Intensive care ultrasound: V. Goal-directed echocardiography. Ann Am Thorac Soc. 2014 Jan;11(1):122-8. De Backer D et al. Intensive care ultrasound: VI. Fluid responsiveness and shock assessment. Ann Am Thorac Soc. 2014 Jan;11(1):129-36 Labovitz AJ et al. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. J Am Soc Echocardiogr. 2010 Dec;23(12):1225-30. Borloz MP et al. Emergency department focused bedside echocardiography in massive pulmonary embolism. J Emerg Med. 2011 Dec;41(6):658-60 . Emergency Ultrasound Tutorials American College of Emergency Physicians: Ultrasound Lectures Previous Next

< Back Tips and Tricks General Tips Despite popular belief, you don’t need a daily CXR for every ICU patient, every intubated patient or every patient with pneumonia/ rib fractures. Don't get daily labs or daily imaging "just because". Get studies that will change your management. For stable patients, you don’t need to check a CBC immediately after every transfusion. You don’t need a PaO2 to wean FiO2. PaO2 is an infinitesimally small contribution to arterial O2 concentration. The equation is often simplified by removing it all together! CaO2= (Hgb x SaO2 x 1.38) + (PaO2 x 0.03) ≈ (Hgb x SaO2 x 1.38) Avoid adjusting multiple meds at one time when addressing a symptom (for example, adding a new medication and increasing the dose of another medication). Too many changes at the same time will make it difficult to know what medication change was responsible if there is a clinical change. Most patients don’t need a CXR after chest tube removal. If the pt has PTX that requires a chest tube, they will tell you (meaning they will be symptomatic). If you check a CXR on everyone, you will find small PTXs that don't need treatment. Not everything that hurts/ bleeds is a hemorrhoid. Exam is required to identify the etiology. If you treat a fissure with hemorrhoid meds (witch hazel, suppositories) they won't get better. Plus, witch hazel will burn and suppositories will be incredibly painful. Patients often get better despite us, not because of us. Many things we believe to be optimal treatment now will be considered heresy in the future. Sometimes not doing something is the best thing to do. Sometimes not operating is the compassionate thing for the patient. A patient doesn’t have to die with an incision on their abdomen. Working with your team Trust the nurse when they say they’re concerned. Better to have a phone call for a patient who is ultimately fine vs not getting a call when the patient isn’t fine. If you respond to nurses by telling them it’s fine and not to worry, they will learn not to call you. If you respond to nurses with hostility, they won’t go out of their way to make your life easier. Don’t call your mid level resident/ chief/ fellow/ attending without any more information than you were initially given. When requesting a consult or calling your chief/ fellow/ attending about a new consult/ admit, give the bottom line upfront. This is especially true when you are waking someone up or need them to do something quickly (ie get dressed and drive in). Tips for the OR While closing fascia, if you maintain counter-traction on the fascia with your pickup as you pass the needle through the fascia, you can release the needle while it’s still in the fascia and reload the needle farther back to push it the remainder of the way through the fascia. Then you can reload the needle and be ready for your next bite without having to touch the needle (decrease risk of needle sticks). Ask for instruments and sutures several steps ahead so you minimize pauses. Always ask for cell saver for a bleeding patient heading to the OR. You don’t want to be delayed waiting for it to be set up before you make your incision. Tips in the Trauma Bay Don’t use GCS 8 as an automatic trigger for intubation. If you intubate before addressing hypovolemia or relieving obstructive physiology, there is a high risk of cardiovascular collapse and asystole. Previous Next

< Back Studying Tips Study Techniques Reading and re-reading textbooks/ notes. Pros- simple. Cons- passive. Easy to not absorb information as your eyes pass over the same text. Reading and highlighting textbooks/ notes. Pros- simple. More interactive than merely reading. Cons- similar to re-reading- still relatively passive. Risk of highlighting everything and not focusing on key points. Reading and handwriting notes in your own handwriting. Pros- active engagement in learning, reframe the information in your own style. You can color-code, reorganize, personalize it. Cons- takes more time. When to study There are two key circadian rhythm patterns. In his book When: The Scientific Secrets of Perfect Timing ," Daniel H Pink refers to these as "chronotypes." There are three chronotypes (larks, owls, and third birds), but the differences between them are largely inconsequential, so they are simplified to two different groups, classically known as early bird and night owl. If you haven't identified your chronotype, you can do a few relatively straightforward steps to determine your pattern. Identifying your chronotype will give you a framework to plan your peak time for analytical tasks, such as studying. If you have any control over your daily schedule, even if it's just weekends, take advantage of your inherent pattern to optimize your studying. Early morning studying before class/ clinical rotations might be optimal for some, while others are more conducive to evening learning. What has worked for me? I used to be a read and re-read type. I'm a fast reader, so it worked to get through high school and medical school. During surgery residency, I used iAnnotate PDF, which allows me to highlight and make notes. When I was entering fellowship, I renovated my style. First, I wrote notes for the handful of critical care texts that I read (Fink and Marino) and the trauma text (Mattox). During the summer before my ACS fellowship, I typed notes while reading Fink and Marino. I used iAnnotate PDF because it allows me to highlight and make notes. I did switch to a hard copy of Civetta because I needed a new format to re-ignite my focus. I used old fashioned lined paper and pencil and then rewrote them into a notebook. After I got burnt out on textbooks, I made the leap to reading journal articles. Switching to primary literature was a monumental change in my studying. I always marvel at attendings who can quote journal articles with ease. It always strikes me that their memory is so crisp...I've never had that gift. When I started reading articles, I developed a system for finding, reading, and then recording the salient findings. How I built my literature database for Acute Care Surgery There are several ways to find articles. Surgical Clinics (previously known as Surgical Clinics of North America) is one of my favorite journals for reviewing broad topics. Every article is evidence-based, with abundant references. The most current journals will be a treasure trove of high-yield references. The open journals and published guidelines (read: free!) are another excellent resource. The references in reviews and guidelines are the basis of evidence-based medicine. Read! You don't have to read every word, and as you read more articles, you will develop a sense of which papers can be perused and which deserve a more diligent review, such as landmark articles (see suggested articles). Highlight, make notes and ask yourself, "how will this change my practice". Previous Next