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< Back A Day in the Life of an Acute Care Surgeon This is a general outline of the daily routine of an Acute Care Surgeon- it does not represent a universal experience, because every facility and every team is unique. Daily schedules vary between the different services. Some facilities have a small enough volume that all three aspects are covered by one surgeon. However, for busy facilities, there can be up to 5-6 surgeons covering the different services. There can be multiple ICU teams to manage, each requiring a surgeon. In-coming trauma might require the full attention of one surgeon, while another surgeon takes care of inpatients and scheduled cases. This is not a guide for how to set up a department- it's just a peek into what we do during the day. The day typically starts with morning report, where overnight events are discussed. This can include trauma and ICU admissions, as well as operative cases. Other significant events such as patients who required transfer to a higher level of care are also discussed. Following morning report, the different services diverge to meet with their teams, either in the OR, in the ICU, or on the inpatient wards. Trauma Service Rounds [the process of evaluating and examining patients currently in the hospital] - Residents typically see the patients first, review their blood work and their x-rays, examine them and ask them pertinent questions to report to their chief resident/ attending. The attending and the chief resident/ senior resident discuss the patients and visit patients in person. There are different practice patterns, and flexibility is required. If the same team is also covering new trauma consults from the emergency department (ED), rounds might be staggered or split based on staffing and patient volume. - Patient evaluation focuses on monitoring patients in the postoperative period, including assessment of bowel function (have you passed gas or had a bowel movement?), nutrition and oral intake (hungry, eating 1/2 of meals, nauseated), pulmonary function (performing breathing exercises), pain control, activity (working with physical therapy, walking laps, breathing exercises), examining wounds, and ruling out surgical complications. Care for patients recovering from trauma also entails communication with subspecialists, such as orthopedics or neurosurgery. Procedures - Emergent operations on new admissions- exploratory laparotomy for intra-abdominal injuries (bowel injury, severe bleeding), thoracotomy for intra-thoracic injuries (severe bleeding, wound to the heart), repair of vascular injuries (bleeding from a blood vessel). - Scheduled operations for patients on the trauma service. Consultations and New Admissions - The majority of patient consults for trauma originate in the ED. Rarely, a patient who is currently admitted to the hospital may be diagnosed with an occult injury (meaning it wasn't found on initial assessment) or a patient may sustain an injury while in the hospital. Surgical Critical Care Rounds - See “What happens during Surgical Critical Care (SICU) Rounds? for details. Procedures - Tracheostomy- creation of a connection directly through the neck to the trachea (airway) to allow removal of the endotracheal tube (breathing tube) from the mouth. - Percutaneous endoscopic gastrostomy tube (PEG)- creation of a connection directly through the anterior abdominal wall into the stomach to allow feeding without requiring a tube in the patient’s nose. - Bronchoscopy- use of a small camera (think of a really skinny colonoscopy) to examine the airways of the lungs, take a specimen for culture or remove obstruction. - Central line placement- placement of a large catheter into a large vein in the neck, under the clavicle (collarbone), or in the groin. The purpose is similar to an IV (intravenous) line, which is commonly placed to provide medication, fluids, or draw blood. A central line is larger- more drips can be connected to it, it can be kept in place longer than a peripheral IV, and it can allow delivery of special medications. - Arterial line placement- similar to an IV, this is a skinny catheter, but instead of being in a vein, it’s placed in an artery. This allows continuous monitoring of blood pressure and allows repeat labs, specifically arterial blood gas to assess respiratory status Consultations and New Admissions - Scheduled or semi-scheduled surgical cases such as complex vascular procedures (aortic surgery, carotid surgery), transplant surgery (patients receive a new liver or kidney), resection of head and neck cancer with a need for management of tracheostomy, and monitoring of muscle flap. - Emergent surgical cases such as a ruptured abdominal aortic aneurysm (thinning of the wall with eventual rupture with bleeding), bowel perforation (hole in the intestine), or any of a variety of surgical catastrophes. - Severely injured trauma patients, including patients who require close monitoring of hemodynamics (low blood pressure, high heart rate) or pulmonary status (ability to take deep breaths with severe trauma to the chest), or patients with head injuries requiring intubation. - Non-ICU patients in lower acuity units that require ICU admission for deterioration in clinical status (respiratory distress, altered mental status, hemodynamic instability). Emergency General Surgery Rounds - Similar to trauma patients as above. For patients who haven’t had surgery (uncomplicated diverticulitis or small bowel obstructions secondary to adhesive disease), close monitoring for changes in clinical status is vital. Procedures - Emergent operations on new admissions- laparotomy for bowel ischemia/ perforation (decreased blood flow to the bowel or a hole in the bowel). - Scheduled operations for patients on the emergency general surgery service, for example, reversal of an ostomy. Patients who undergo emergent surgery for trauma or bowel ischemia/ perforation sometimes require creation of an opening on the skin to allow stool to pass outside into a bag. These can be “reversed”, meaning the bowel is reconnected (so the patient will now pass stool normally) and the skin opening is closed. Consultations and New Admissions - Patient consults typically originate in the ED. Everything from abdominal pain to rectal pain to massive intestinal bleeding can prompt a phone call/ page/ text message to the Emergency General Surgery service. - Patients admitted for non-surgical diseases can develop a surgical emergency during their hospital admission. This includes diagnoses that typically prompt a visit to the ED (appendicitis, cholecystitis), but there are a host of other diagnoses that are more frequent in the hospital setting, such as C. difficle colitis. In addition to daily responsibilities, there are weekly or monthly department-wide events. - Staff Meetings - Trauma Morbidity and Mortality- discuss outcomes from trauma cases. - General Surgery Morbidity and Mortality- discuss outcomes from general surgery cases. - Grand Rounds- lectures from subject matter experts on various surgical topics. Previous Next

2 Critical Care Lectures Vents .pdf Download PDF • 7.24MB Respiratory Failure .pdf Download PDF • 4.85MB Electrolyte Imbalance .pdf Download PDF • 3.88MB Acid Base Basics .pdf Download PDF • 1.14MB Kidney Injury .pdf Download PDF • 8.05MB Hemodynamics .pdf Download PDF • 9.86MB Heart POCUS .pdf Download PDF • 55.03MB Nutrition .pdf Download PDF • 3.52MB Ultrasound .pdf Download PDF • 84.19MB Blood .pdf Download PDF • 4.92MB Pain Delirium Agitation .pdf Download PDF • 16.05MB

6 < Back EGS Resources Society Guidelines EAST Practice Management Guidelines. Evidence-based guidelines developed and published by EAST. Covers EGS, ICU, trauma, and injury prevention. World Society of Emergency Surgery (WSES). Guidelines and reviews covering topics including trauma, pancreatitis, colitis, cholecystitis, and large bowel malignancy, and many others. American Society of Colon and Rectal Surgeons (ASCRS) Clinical Practice Guidelines. Guidelines on common colo-rectal diseases such as diverticulitis, preoperative bowel preparation, hemorrhoids, and colorectal cancer. Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Guidelines and Clinical Reviews. Guidelines include cholecystitis, ERAS protocol, choledocholithiasis, laparoscopy, to name a few. American Society for Gastrointestinal Endoscopy (ASGE). Evaluation, diagnosis and management of patients undergoing GI endoscopy. Previous Next

What language are we speaking? Speaking Greek < Back What language are we speaking? Medicine has a language all its own. Sometimes we use formal words for common terms, like sputum or phlegm to refer to snot. But a lot of words are unique to the medical field. When speaking with patients and families, the most important thing is communicating effectively. Using a slew of foreign and formal words might sound impressive, but everyone will likely be more confused when you leave the room. After years of education and training, words and phrases in the medical dictionary become second nature. Our conversations with colleagues, consultants, and peers are frequently saturated with this unique lexicon. Sometimes this even spills into your conversations outside of work, and your family and friends might start to pick up some of your common work terms. Patients and their families are not fluent in the language of healthcare unless they are employed in healthcare or have experienced frequent interactions with the healthcare field, such as being a caregiver for an ill family member or suffering from a chronic illness. Once you learn something, it’s difficult to remember a time when you didn’t know. If you’ve worked in healthcare, it’s obvious that laparoscopic cholecystectomy means using tiny incisions and long instruments to remove the gallbladder through the belly button. But unless you’ve had one yourself or know someone who has had one, these words might have little meaning. This language barrier can be even more challenging in the stressful environment encountered in the ICU. Several factors create additional barriers to effective communication. 1. Patients in the ICU are sicker and the threat of death or serious disability is more apparent. This can create emotional distress that occupies or distracts families as they try to ask questions and get answers, impairing their ability to thoroughly understand, even if the healthcare team provides very detailed, comprehensive information. 2. When individuals receive bad news, they process/ remember very little after the initial shocking revelation. 3. The higher acuity and sometimes the need for urgent intervention can add time constraints. This creates an additional barrier to effective communication- having to convey the information and potentially obtain consent for treatment and procedures while balancing the ever-present demands of multiple urgent procedures and critical patients to attend to. Families can get information from different members of the healthcare team. Sometimes the nature of the conversation demands the skills of the most experienced provider. However, young trainees sometimes converse with families as well. It’s easy to forget the process of learning how to effectively communicate with families in difficult situations. Listening to phone conversations between team members and family can be enlightening. As young trainees are becoming much more facile with the unique language of the ICU, it can start to infiltrate these discussions. For example, imagine you are caring for a patient who was just admitted to the ICU with a severe traumatic brain injury. When you’re reporting to the accepting team, you’ll use words like subdural hematoma, midline shift, cerebral edema, and severe TBI. When discussing the patient's current clinical status, you might mention that they are over-breathing the ventilator or that they don’t have brainstem reflexes. When developing a management plan, you might discuss the utility of ICP monitoring and debate the use of a bolt or an EVD, the benefits of hypertonic saline versus mannitol for hyperosmolar therapy, whether or not to hyperventilate the patient and the potential for a craniectomy. While these will be readily understood by your colleagues, these are likely foreign terms for most family members. So here are some tips for talking to family and friends, especially during initial conversations. 1. Avoid unfamiliar medical terminology (for example: severe TBI, hypertonic saline). Instead, opt for descriptors such as “bad head injury” or “medication to protect the brain”. 2. Avoid unnecessary details. Don’t ramble on about everything that has happened, especially while they are waiting to hear if their loved one is alive or dead. After you’ve told them their family member is alive, they aren’t likely to hear much else. 3. Avoid revealing that a patient has died over the phone, especially in your initial discussion with the family. 4. Avoid acronyms (for example: TBI, GCS) 5. DO give them a chance to ask questions. 6. DO encourage them to write down their questions as they think of them and reassure them that they can ask questions throughout the process. Previous Next

How to be a Terrible First Date Dating, Pt 2 How to be a Terrible First Date Recently, I was set up on a blind date. He seemed like a normal mature guy via text. Polite, intelligent responses, etc. We agreed to meet at a local bakery. My first clue should have been the fact that he didn't have the fortitude to message me first. I don't do a great job of taking my own advice…I had told myself I wouldn't message first, that he would have to be the guy and reach out first. Oops. When I showed up, he was sitting outside. I sat down and he asked if I wanted to order something. He told me they have great food and good coffee, to which I replied that I don't drink coffee. And the date careened downhill from there. His response? Not drinking coffee is a red flag that a woman isn't a good partner. Goes along with not liking chocolate. He declared that if something else goes wrong later in the relationship, you can look back and say yeah they told me there was something wrong from the beginning. Then he went off on a tangent about how people who don't eat the same kind of foods won't be compatible in relationships. For example a vegetarian and a vegan. More specifically, a really douchey vegetarian or vegan. I didn't know people still used that word…actually, I didn't know that it was ever used out loud as an adjective by a guy. He continued with other crazy comparisons. Like Jewish people who don't eat pork. Or cannibals. Or carnivores. Told me a story about having a friend who ate dogs. Some context for the dog-eating conversation-- there was an adorable medium-sized fluffy black and white dog sitting about 3 feet away from us. He and his owner are clearly within earshot. He continued…."do you see that dog right there, she (his friend from Asia) would think it would be OK to eat a dog." I didn't know what to say to that. All I could say at that point was that I could never eat that dog, that I couldn't even kill a dog! His monologue about eating continued with an explanation of why humans are the superior beings on the planet. The bottom line was that the thing that makes us the superior being is the fact that we can eat any other animal. It's not our intelligence (dolphins are more intelligent), it's not our technology, we aren't faster or braver. But we can eat any animal. And somehow he related this to the use of smartphones- using a smartphone doesn't make you smart. A stupid person can use a smartphone but still eat any animal. He then delved further into the world of food and eating with a rant about McDonald's. You’ve heard of McDonald's, right? Are you too good to eat at McDonald's? Have you heard of Jim Gaffigan? He does a skit about McDonald's. You ever run into someone at a McDonalds’s and they ask what you’re doing there...you just pretend you’re meeting a hooker. Him: McDonald’s fries are the best thing. Me: not if they’re cold. Him: Well you have to eat them within 5 minutes. After those five minutes, they’re no longer food. Me: But they aren’t always warm when you get them. Him: Then that’s your fault. If you don’t check and you drive away, it’s on you. You can’t blame anyone else. Me: But who wants to be the person who holds up the line in the drive-thru? Him: You have to be coordinated, pay, and inspect the fries all at the same time. And if they’re cold, you hand them back and say these are cold I need new fries. And everyone in that line behind you will understand that. If you drive away and the fries are cold, it's your fault. I tried to change the subject by commenting on the restaurant. Told him there was a place I previously lived that had similar food, but the décor on the inside was quirky. It was awesome because it was open 24/7. His response…there weren't other places open 24/7? IHOP? I asserted that there were not many places….maybe Huddle House. He said he's never been to a Huddle House. I said it's like a worse version of Waffle House. He said, have you ever been to a Waffle House? It's like a truck stop bathroom with a kitchen. I told him, yes, and that Huddle House must be an East Coast thing. He told me they don't have it up north, so I said Ok, maybe it’s a North Carolina thing. Why does everything have to be a disagreement??? Finally, after complaining about not wanting to give up the table he picked, he agreed that we should go in and order food. When we were in line to order, the conversation took on a slightly different tone. He proceeds to lecture me on the fact that making requests or asking questions regarding food at a restaurant is a personality flaw. He also told me that you need to try everything at least twice. Without even knowing me, he was insulting people who make requests at a restaurant. He made some mention of bacon, and I said I don't care for bacon, and asked whether not liking bacon is as bad as not liking coffee or chocolate? He said that's not a big deal in Texas, maybe in North Carolina or Georgia it would be (the last two places I've lived…again, he knows nothing about me). When I asked why I have to try something else two more times when I already know what I like (or don't like), he said, what if you get to be 80 years old, and your tastes have changed? He told me, just go with the flow….he said if he orders beans and they give him rice instead, he'll just eat the rice. Me: But what if you really want beans. Him: Just go with it, order the beans next time. Some people eat dirt and mud. Me: Just because there are people who have to eat dirt doesn't mean we just have to eat whatever is given to us. Him: Don't ask a lot of questions to someone who barely has a high school education. So basically…he doesn't have a spine to ask for what he wants when he eats out. Probably translates into other areas of his life where he isn't able to stand up for himself…just a guess. So now that he's already insulting people who have preferences about food, I had to tell him about a recent outing with work colleagues. We went to an outdoor American food place, and I wanted a plain burger. The only thing they had on the menu was a burger with brisket on top. So I asked my friends if that meant brisket sauce or actual brisket meat. Immediately, my date tells me I asked too many questions. I tried to play along, acquiescing that barbeque is a big deal in Texas. But then, I said I don't eat that much food at one time and I didn't want more meat on my burger. He told me not to complain, and just eat half and give it to a homeless person. He told a story about giving food to a homeless person once in Austin…the homeless person asked if it was gluten-free, and then when he said I'm not sure, and the homeless person said, ok, never mind. So a weird humble brag, talking bad about a homeless person while simultaneously telling me he is a generous person. So again, it was my turn to tell a story about myself to see how he'd insult me some more. Me: I went to a restaurant that I really liked back home and I like the green beans there. I went there one time and they didn't have green beans. Him: You can be sad about that but don't be whiny about it. The restaurant was relatively crowded, kinda looked more like a Saturday morning than a Thursday morning. He did that awkward thing where he says rude things out loud so everyone around us can hear him being insulting. Him: Why are there so many people here? It's a Thursday morning. These people should be at their jobs. Me: You do realize we are here, right? The menu advertised a breakfast sandwich…which I guess I was going to order but had to make sure not to ask questions or tell them what I want. In an attempt to make a sarcastic joke, he asked about whether the sandwich was gluten-free. And if the chickens were free-range. I made a joke and asked if the chickens were treated well and whether they were mocked as children. When we got back outside, he complains about the fact that the table he had been sitting at was taken. Then he walks around and complains that the rest of the tables are equally bad. Not so easy going now, eh?? We sat outside, and as we were waiting for our food, several birds were dive-bombing me, to which I responded like a normal person and ducked. He proceeded to chastise me for not standing up to the bird and not asserting my dominance. He told me it didn't bode well for my offspring that I couldn't stand up to a bird. Stated I would just let my children be pecked to death by birds. Said I'd be helpless, and hopeless for the rest of my life. Literally used those words. Not even implied, straight out said I was hopeless and helpless. Somehow we got on the conversation of working, basically said he only does his job to make money. I asked him if he enjoyed it or enjoyed helping people, and he said being a neurologist was the best he could come up with using the advantages he was born with. He said there was nothing better he could do to make money, to which I replied that he was choosing to limit himself. While we waited, he decided to give me a lesson on animals and nature. On nature shows, the lion is shown as the majestic king of the jungle, but they hide the fact that lions will eat their young. This part was much funnier in person because his tone of voice and storyline was so ridiculous. Like he was actually offended or thought it was a conspiracy that this wasn't shown on TV. He also gave a long monologue about how big birds eat other birds. Like helpless penguins. Birds try to eat their eggs. Sometimes the big bird will be looking down and the other bird knows it's about to get eaten. Other times, the other bird doesn't even know. It'll just be sitting there one moment, and the next moment, hey I'm being eaten. When I turned and spoke to one of the many dive-bombing birds, he proceeded to correct me about calling a bird the wrong gender. He stated that men are the brighter of the bird species because they have to attract the female bird. Told me about watching a show that talked about males of different species trying to attract females. Like fish get the rocks all together to show the girl fish that they can make a nice place, and then the girl fish comes over, so the male fish does a dance, and then if they get turned down by a female, they clean up the rocks and try again. Birds try to make the best nest to impress female birds. Then he told me that males are brighter than females, across all species. To which I disagreed, stating that I don't think men are more colorful than women. He corrected me, saying that’s why men wear ties…. Again, I told him I'm pretty sure females are more colorful. And he said, yea, women just like to shop. He also told me he could tell which was a female bird because they were the ones that ate everything. Yes, he said those words. Out loud. To a woman he'd never met. Throughout the date, he spent 97% of the date not talking about me or asking about me. I did proceed to tell him about the time I was attacked by dogs. And I told him it changed my life. He responded by asking (at least twice) what I did to the dogs to make them attack me. Seriously. Told him my story about the dogs. After I finished, he asked if I was bleeding. I recounted my story of going to the ER…to which he responded with…nothing. No sympathy. No nothing. Told him the rabies shot is really painful because they had to put it in my ankle. He said they probably did it wrong and it was his goal in life to never need a rabies shot. I then told him about how it changed the nature of my deployment…again, no questions about me. I told him it was odd to talk about birds eating each other on a first date. And I didn't know how he planned to get second dates after that conversation. He said he had watched a documentary with his niece and it was something he learned. Then he asked me what I learned. And then just stopped talking and went back to eating. Didn't even eat half my breakfast…so uncomfortable, and I wondered if he would tease me for eating all my food. By the way, he also sat with his feet on the chair next to me, legs straight. Back when we were in line ordering breakfast, I asked if he was cold, cause he had long pants, a sweater, and a long black wool coat. He said, no, he wore that so he wasn't cold… During breakfast, he told me because I had my arms folded that I was either cold or standoffish. Said that a few times over and over to me…and he even mocked me by folding his arms tightly across his chest and scowling. I then laid my hands on the table in front of me. He continued to mock me. Later, he noticed goosebumps and told me I was cold. And then told me because I wasn't furry (or hairy, I don't remember), goosebumps mean I'm cold. Later on, we took a walk along the river walk. It was mostly painfully awkward silence. But a few times, he did that weird thing talking out loud saying awkward things that other people can hear… There was a lady behind us with a stroller. He said, "I feel like we're being followed". Later, a yappy little dog barked at us, to which he said "no kill, no kill". The only interesting thing he talked about was racing cars. He mostly mumbled quietly, but I encouraged him to speak up and finally learned something interesting about him. He races cars- most recently a Ferrari, and he just bought a Lotus that he is getting ready for racing. He also used to race a Honda Accord. Reminds me of an ex-boyfriend who drove a Ford Taurus, but was convinced that just because he could hit the gas pedal hard, he was a race car driver… And then, just like that, mercifully, the torture was over. He walked us back to his car, pointed it out, and then walked away. Didn't ask where I parked or offer to walk me back. Again, all the little things can be written off as one-offs. Ok, fine, he didn't walk me to my car. Fine, he put his feet on the chair next to me. Yadda yadda yadda. But all together within like an hour? Come Previous Next

6 Note Templates Trauma Admit Note Template .pdf Download PDF • 31KB ICU Progress Note Template .pdf Download PDF • 21KB ICU Rounds Sheets .pdf Download PDF • 46KB Extubation Note .pdf Download PDF • 30KB

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

< Back Bowel Anastomosis A handsewn small bowel anastomosis can be created end to end or side to side. When creating a side to side anastomosis, the planned enterotomy site on each limb of bowel is identified. The backwall is created first, just lateral to the planned enterotomy sites- it would be very challenging to access this portion of the anastomosis after creating the inner layer. The back layer is followed by inner layers of absorbable suture. My personal preference is Vicryl, but PDS can also be used. Finally, the anterior outer seromuscular layer of silk is created. Posterior outer layer of interrupted 3-0 Silk Limbert sutures Posterior inner layer of interrupted 3-0 Vicryl sutures Anterior inner layer of Connell with 3-0 Vicryl Anterior outer layer or interrupted 3-0 Silk Limbert sutures Inner layer of absorbable sutures and outer seromuscular layer of silk. Two different depictions of side to side anastomoses (1,2). Rao SD. Small Intestine, In: Snapshots in Gastroenterology. Jaypee Brothers Medical Publishers (P) Ltd. 2016. Rao SD. Pre- and Postoperative Management in Midgut (Small Bowel) Surgery, In: Gastrointestinal Surgery Step by Step Management. Jaypee Brothers Medical Publishers (P) Ltd. 2005. Previous Next

< 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