Currently reading, Books to Read, Books I've Read Books Currently Reading Currently Reading The Last Murder at the End of the World Books I Want to Read: Fiction Crime/ Mystery The Last Thing He Told Me Big Lies in a Small Town The Appeal All Good People Here Happiness Falls The Cloisters Murder Your Employer: The McMasters Guide to Homicide The God of the Woods The Devil and the Dark Water Crime/ Mystery: Series Three Pines (Chief Inspector Gamache) : The Grey Wolf (#19) Killers of a Certain Age : Kills Well with Others (#2) Thomas De Quincey : Ruler of the Night (#3) Kaely Quinn Profiler : Fire Storm (#2) and Dead End (#3) Charles Lenox Mysteries : An Extravagant Death (#14), The Hidden City (#15) Dr. Thomas Silkstone : Secrets in the Stones (#6) The Checquy Files : Stiletto (#2) and Blitz (#3) Rabbit Factor: The Moose Paradox (#2) and The Beaver Theory (#3) Detective Rupert Max : The Guise of Another (#2), The Heavens May Fall (#3), The Deep Dark Descending (#4), The Shadows We Hide (#5), and Forsaken Country (#6) Nell Ward Mysteries : A Swarm of Butterflies (#6, expected August 2024) Death in Paradise : A Meditation on Murder (#1), The Killing of Polly Carter (#2), Death Knocks Twice (#3), and Murder in the Caribbean (#4) Castle Knoll Files : How to Seal Your Own Fate (#2, expected March 2025) Verity Kent Mysteries : Treacherous Is the Night (#2), Penny for Your Secrets (#3), A Pretty Deceit (#4), Murder Most Fair (#5), A Certain Darkness (#6), and The Cold Light of Day (#7) Terminal List : The Terminal List (#1), True Believer (#2), Savage Son (#3), The Devil’s Hand (#4), In the Blood (#5), Only the Dead (#6), and Red Sky Mourning (#7) Gabriela Rose : The Recovery Agent (#1) and The King’s Ransom (#2) Joe Talbert : The Stolen Hours (#3) Detective Max Rupert : The Deep Dark Descending (#4) and Forsaken Country (#5) Ernest Cunningham : Everyone in My Family has Killed Someone (#1), Everyone on this Train is a Suspect (#2), and Everyone This Christmas has a Secret (#3) Sebastian St. Cyr Ruth Galloway (by Elly Griffiths) Harbinder Kaur (by Elly Griffiths) The Brighton Mysteries (by Elly Griffiths) Ernest Cunningham No. 1 Ladies' Detective Agency Lady Sherlock Hercule Poirot (Agatha Christie) Kovac and Liska Assistant to the Villain D.I. Lottie Parker Cormac Reilly Stewart Hoag The Charity Shop Detective Agency Erast Fandorin Mysteries Maisie Dobbs Colin Pendragon Mysteries Blythe Baker (multiple mystery series) Historical Fiction Kate Quinn: The Huntress , The Diamond Eye Kristin Harmel: The Book of Lost Names , The Forest of Vanishing Stars , The Winemaker's Wife Marie Benedict: The Other Einstein , The Only Woman in the Room Kristin Hannah: The Nightingale The Frozen River The Lost Girls of Paris The Lobotomist's Wife The Paris Library The Clockmaker's Daughter The Bookbinder Transcription Dangerous Women The Frozen River Science Fiction/ Fantasy A Quantum Love Story Last Night in Montreal Hummingbird Salamander Recursion Book of Doors Shark Heart The Lost Bookshop Matt Haig: The Life Impossible , The Possession of Mr. Cave , The Humans Science Fiction/ Fantasy: Series Borne : Borne (#1), The Strange Bird (#1.5), Dead Astronauts (#2) Winternight Trilogy : The Bear and the Nightingale (#1), The Girl in the Tower (#2), and The Winter of the Witch (#3) Red Rising Saga : Red Rising (#1), Golden Son (#2), Morning Star (#3), Iron Gold (#4), Dark Age (#5), Light Bringer (#6), and Red God (#7) Romance/ Chick Lit The Wise Women The Unmaking of June Farrow The Wedding People Novels/ Series Murphy Shepherd: The Water Keeper (#1), The Letter Keeper (#2), and The Record Keeper (#2) Harold Fry : The Love Song of Miss Queenie Hennessy (#2) and Maureen (#3) The Hundred-Year-Old Man : The Accidental Further Adventures of the Hundred-Year-Old Man (#2) Ann Leary: The Good House and The Children Lonesome Dove The Book with No Pictures Books I've Read: Fiction Crime/ Mystery Paula Hawkins Collection: The Girl on the Train , A Slow Fire Burning Liane Moriarty Collection: Nine Perfect Strangers , Apples Never Fall Lucy Foley Collection: The Guest List , The Paris Apartment (read first half) A Most Agreeable Murder The Witch Elm Sometimes I Lie Before the Fall The Lovely Bones Burglars Can't Be Choosers The 7 1/2 Deaths of Evelyn Hardcastle Wrong Place, Wrong Time The House in the Pines The Golden Spoon Killers of a Certain Age The Bequest The Lifeguards The Truth about the Harry Quebert Affair The Truth and Other Lies The Finishing School Mother-Daughter Murder Night The Woman in the Library The Last Flight Crime/ Mystery: Series Three Pines (Chief Inspector Gamache) : Still Life (#1), A Fatal Grace (#2), The Cruelest Month (#3), A Rule Against Murder (#4), The Brutal Telling (#5), Bury Your Dead (#6), A Trick of the Light (#7), The Beautiful Mystery (#8), How the Light Gets In (#9), The Long Way Home (#10), The Nature of the Beast (#11), A Great Reckoning (#12), Glass Houses (#13), Kingdom of the Blind (#14), A Better Man (#15), All the Devils are Here (#16), The Madness of Crowds (#17), and A World of Curiosities (#18) Cormoran Strike : Cuckoo's Calling (#1), The Silkworm (#2), Career of Evil (#3), Lethal White (#4), Troubled Blood (#5), The Ink Black Heart (#6), and The Running Grave (#7) Thomas De Quincey : Murder as a Fine Art (#1) and Inspector of the Dead (#2) Dublin Murder Squad : In the Woods (#1), The Likeness (#2), Faithful Place (#3), Broken Harbor (#4), The Secret Place (#5), and The Trespasser (#6) Hawthorne and Horowitz : The Word is Murder (#1), The Sentence is Death (#2), A Line to Kill (#3), The Twist of a Knife (#4), and Close to Death (#5) Susan Ryeland : Magpie Murders (#1) and Moonflower Murders (#2) Sam Clair : A Murder of Magpies (#1), A Bed of Scorpions (#2), A Cast of Vultures (#3), and A Howl of Wolves (#4) Quantico Files : Night Fall (#1), Dead Fall (#2), and Free Fall (#3) Kaely Quinn Profiler : Mind Games (#1) Jack Reacher : The Killing Floor (#1) and Die Trying (#2) Charles Lenox Mysteries : A Beautiful Blue Death (#1), The September Society (#2), The Fleet Street Murders (#3), A Stranger in Mayfair (#4), An East End Murder (#4.5), A Burial at Sea (#5), A Death in the Small Hours (#6), An Old Betrayal (#7), The Laws of Murder (#8), Home by Nightfall (#9), The Inheritance (#10), Gone Before Christmas (#10.5), The Woman in the Water (#11), The Vanishing Man (#12), and The Last Passenger (#13) Thursday Murder Club : Thursday Murder Club (#1), The Man Who Died Twice (#2), The Bullet That Missed (#3), and The Last Devil to Die (#4) Nell Ward Mysteries : A Murder of Crows (#1), A Cast of Falcons (#2), A Mischief of Rats (#3), A Generation of Vipers (#4), and A Traces of Hares (#5) Molly the Maid : The Maid (#1) and The Mystery Guest (#2) Cal Hooper : The Searcher (#1) and The Hunter (#2) Dr. Thomas Silkstone : The Anatomist’s Apprentice (#1), The Dead Shall Not Rest (#2), The Devil’s Breath (#3), The Lazarus Curse (#4), and Shadow of the Raven (#5) The Checquy Files : The Rook (#1) Letty Davenport : The Investigator (#1) and Dark Angel (#2) The Marlow Murder Club : The Marlow Murder Club (#1), Death Comes to Marlow (#2), and The Queen of Poisons (#3) Inspector Ian Rutledge : A Test of Wills (#1) Detective Varg : The Department of Sensitive Crimes (#1), The Strange Case of the Moderate Extremists (#0.8), The Talented Mr. Varg (#2), The Man with the Silver Saab (#3), and The Discreet Charm of the Big Bad Wolf (#4) Castle Knoll Files : How to Solve Your Own Murder (#1) Charlotte and Thomas Pitt : The Cater Street Hangman (#1) Rabbit Factor : The Rabbit Factor (#1) Joe Talbert : The Life We Bury (#1) and The Shadows We Hide (#2) Detective Max Rupert: The Guise of Another (#2) and The Heavens May Fall (#3) Verity Kent Mysteries : This Side of Murder (#1) We Solve Murders : We Solve Murders (#1) Historical Fiction Nora Beady : The Girl in His Shadow (#1) and The Surgeons Daughter (#2) Kate Quinn: The Alice Network , The Rose Code Kristin Hannah: The Women Ann Leary: The Foundling All the Light We Cannot See The Kitchen Front Code Name Hélène The Dictionary of Lost Words The Lost Apothecary The Miniaturist The Book of Speculation The Summer Before the War Science Fiction/ Fantasy Matt Haig: The Midnight Library , How to Stop Time Neil Gaiman: Neverwhere , Stardust , Trigger Warning: Short Fictions and Disturbances Emily St. John Mandel: Station Eleven , Sea of Tranquility , The Glass Hotel A Wrinkle in Time Hitchhikers Guide to the Galaxy The Coincidence Makers The Invisible Life of Addie LaRue Spoonbenders The Impossible Lives of Greta Wells The First 15 Lives of Harry August The Alchemist Other Birds Good Morning, Midnight Day Tripper Science Fiction/ Fantasy: Series Maze Runner : The Maze Runner (#1), The Scorch Trials (#2), The Death Cure (#3), The Kill Order (#4), and The Fever Code (#5) Divergent : Divergent (#1), Insurgent (#2), Allegiant (#3), and Four (#4) Red Queen : Red Queen (#1), Glass Sword (#2), and King's Cage (#3) Southern Reach : Annihilation (#1), Authority (#2), and Acceptance (#3) Shades of Magic (VE Schwab): A Darker Shade of Magic (#1) Caraval : Caraval (#1), Legendary (#2), Finale (#3) Mither Mages (Orson Scott Card): The Lost Gate (#1), The Gate Thief (#2), and The Gatefather (#3) The Mortality Doctrine : The Eye of Minds (#1) Wayward Children : Every Heart a Doorway (#1) Romance/ Chick Lit The Bookish Life of Nina Hall : The Bookish Life of Nina Hall (#2), Adult Assembly Required (#2) Katherine Center: Things you save in a Fire , What You Wish For , The Bodyguard The Art of Hearing Heartbeats Lessons in Chemistry The Queen of Hearts Oh Dear Silvia Ghosted The Overdue Life of Amy Byler My (not so) Perfect Life Foreign Affairs Humor Eleanor Oliphant is Completely Fine Nothing to See Here The Answer is No Novels Phaedra Patrick Collection: The Curious Charms of Arthur Pepper , The Messy Lives of Book People , The Library of Lost and Found , The Secrets of Love Story Bridge Jodi Picoult Collection: Wish You Were Here , The Book of Two Ways Tomorrow, and Tomorrow, and Tomorrow A Week in Winter Seven Days of Us I Miss You When I Blink Ella Minnow Pea The Keeper of Lost Things Gravity is the Thing The School for Good Mothers Something to Live For (Previously: How not to die alone) Anxious People The Gifted School Wicked Leaks A Thousand Pardons The Department of Rare Books and Special Collections Remarkably Bright Creatures The Chemist Series Millennium : The Girl with the Dragon Tattoo, The Girl Who Played with Fire, The Girl Who Kicked the Hornet's Nest, The Girl in the Spiders Web, The Girl who takes an Eye for an Eye, The Girl Who Lived Twice Penumbra : Mr. Penumbra's 24-Hour Bookstore and Ajax Penumbra 1969 Don Tillman : The Rosie Project (#1), The Rosie Effect (#2) Harold Fry : The Unlikely Pilgrimage of Harold Fry (#1) Olive Kitteridge : Olive Kitteridge (#1) The Hundred-Year-Old Man : The 100-Year-Old Man Who Climbed out the Window and Disappeared (#1) Books I Want to Read: Non-Fiction Business The Innovator's Dilemma: The Revolutionary Book that Will Change the Way You Do Business History Civilizations Rise and Fall (Jared Diamond): Guns, Germs, and Steel: The Fates of Human Societies (#1), Collapse: How Societies Choose to Fail or Succeed (#2) and Upheaval: Turning Points for Nations in Crisis (#3) Climbing and Adventures Shackleton's Way: Leadership Lessons from the Great Antarctic Explorer Buried in the Sky: The Extraordinary Story of the Sherpa Climbers on K2's Deadliest Day Over the Edge of the World: Magellan's Terrifying Circumnavigation of the Globe Touching the Void: The True Story of One Man's Miraculous Survival The Next Everest: Surviving the Mountain's Deadliest Day and Finding the Resilience to Climb Again The Boys of Everest: Chris Bonington and the Tragedy of Climbing's Greatest Generation Forever on the Mountain: The Truth Behind One of Mountaineering's Most Controversial and Mysterious Disasters The Climb: Tragic Ambitions on Everest Climb: Stories of Survival from Rock, Snow and Ice Medical Nine Pints: A Journey Through the Money, Medicine, and Mysteries of Blood Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted Blood and Guts: A History of Surgery Confessions of a Surgeon: The Good, the Bad, and the Complicated...Life Behind the O.R. Doors Do No Harm: Stories of Life, Death and Brain Surgery You Can Stop Humming Now: A Doctor's Stories of Life, Death and in Between When We Do Harm: A Doctor Confronts Medical Error Diagnosis: Solving the Most Baffling Medical Mysteries This is Going to Hurt: Secret Diaries of a Young Doctor Swallow: Foreign Bodies, Their Ingestion, Inspiration, and the Curious Doctor Who Extracted Them Expert: Understanding the Path to Mastery Women in White Coats: How the First Women Doctors Changed the World of Medicine You Bet Your Life: From Blood Transfusions to Mass Vaccination, the Long and Risky History of Medical Innovation Attending: Medicine, Mindfulness, and Humanity Psychology: Individual How We Decide Algorithms to Live By: The Computer Science of Human Decisions How Not to Be Wrong: The Power of Mathematical Thinking Amazing Decisions: The Illustrated Guide to Improving Business Deals and Family Meals The Logic of Failure: Recognizing and Avoiding Error in Complex Situations Sway: The Irresistible Pull of Irrational Behavior Anatomy of a Secret Life: The Psychology of Living a Lie The Secret Life of the Mind: How Your Brain Thinks, Feels, and Decides Gut Feelings: The Intelligence of the Unconscious Superminds: The Surprising Power of People and Computers Thinking Together Incognito: The Secret Lives of the Brain The Paradox of Choice: Why More Is Less The Forgetting Machine: Memory, Perception, and the Jennifer Aniston Neuron Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones How Emotions Are Made: The Secret Life of the Brain Psychology: Interacting with Others The Stuff of Thought: Language as a Window into Human Nature Invisible Women: Data Bias in a World Designed for Men Shape: The Hidden Geometry of Information, Biology, Strategy, Democracy, and Everything Else Rock Breaks Scissors: A Practical Guide to Outguessing and Outwitting Almost Everybody The Confidence Game: Why We Fall for It . . . Every Time Reading People: How Seeing the World through the Lens of Personality Changes Everything The Wisest One in the Room: How You Can Benefit from Social Psychology's Most Powerful Insights Connected: The Surprising Power of Our Social Networks and How They Shape Our Lives The Lucifer Effect: Understanding How Good People Turn Evil Flash Boys: A Wall Street Revolt The Bed of Procrustes: Philosophical and Practical Aphorisms / Nassim Nicholas Taleb Expert Political Judgment: How Good Is It? How Can We Know? / Philip Tetlock Unmaking the West: "What-If?" Scenarios That Rewrite World History / Philip Tetlock Counterfactual Thought Experiments in World Politics: Logical, Methodological, and Psychological Perspectives / Philip Tetlock Biography Furiously Happy: A Funny Book About Horrible Things Broken (In the Best Possible Way) Self-Help Tiny Beautiful Things: Advice from Dear Sugar Crime The Casebook of Forensic Detection: How Science Solved 100 of the World's Most Baffling Crimes Books I've Read: Non-Fiction Medical When Breath Becomes Air How Doctors Think Cheating Death: The Doctors and Medical Miracles that Are Saving Lives Against All Odds Stiff: The Curious Lives of Human Cadavers The Naked Lady Who Stood on Her Head: A Psychiatrist's Stories of His Most Bizarre Cases Admissions: Life as a Brain Surgeon Patient H.M.: A Story of Memory, Madness, and Family Secrets Under the Knife: A History of Surgery in 28 Remarkable Operations Medical: By Atul Gawande Being Mortal: Medicine and What Matters in the End Checklist Manifesto: How to Get Things Right Better: A Surgeon's Note on Performance Complications: A Surgeons Notes on an Imperfect Science Under the Knife: A History of Surgery in 28 Remarkable Operations Crime Never Sucks a Dead Man's Hand: Curious Adventures of a CSI Climbing Adventures Into Thin Air: A Personal Account of the Mt. Everest Disaster Biography Unbroken: A World War II Story of Survival, Resilience, and Redemption Scrappy Little Nobody: Anna Kendrick Bossypants: Tina Fey Maybe You Should Talk to Someone: A Therapist, HER Therapist, and Our Lives Revealed Let’s Pretend This Never Happened: A Mostly True Memoir Social Psychology Lying Leonard Mlodinow: The Drunkards Walk: How Randomness Rules our Lives and Elastic: Unlocking Your Brain's Ability to Embrace Change Daniel Kahneman: Thinking, Fast and Slow and Noise: A Flaw in Human Judgment Scienceblind: Why Our Intuitive Theories About the World Are So Often Wrong Contagious: Why Things Catch On Made to Stick: Why Some Ideas Survive and Others Die A Field Guide to Lies: Critical Thinking in the Information Age Loonshots: How to Nurture the Crazy Ideas That Win Wars, Cure Diseases, and Transform Industries When: The Scientific Secrets of Perfect Timing You Are Not So Smart Behave: The Biology of Humans at Our Best and Worst Grit: The Power of Passion and Perseverance Range: Why Generalists Triumph in a Specialized World Originals: How Non-Conformists Move the World Everybody Lies: Big Data, New Data, and What the Internet Can Tell Us About Who We Really Are Everything is Obvious: Once You Know the Answer The Disappearing Spoon: And Other True Tales of Madness, Love, and the History of the World from the Periodic Table of the Elements Freakanomics: A Rogue Economist Explores the Hidden Side of Everything Farsighted: How We Make the Decisions That Matter the Most Superforecasting: The Art and Science of Prediction Barking up the Wrong Tree: The Surprising Science behind why everything you know about success is [mostly] wrong Quirky: The Remarkable Story of the Traits, Foibles, and Genius of Breakthrough Innovators Who Changed the World Start with Why: How Great Leaders Inspire Everyone to Take Action Team of Teams: New Rules of Engagement for a Complex World The Knowledge Illusion: Why we never think alone The Signal and the Noise: Why So Many Predictions Fail--but Some Don't The Basic Laws of Human Stupidity Incerto/ Nassim Nicholas Taleb : Skin in the Game: Hidden Asymmetries in Daily Life, Fooled by Randomness: The Hidden Role of Chance in Life and in the Markets and Black Swan: The Impact of the Highly Improbable Social Psychology: By Malcolm Gladwell Outliers: The Story of Success The Tipping Point: How Little Things Can Make a Big Difference Blink: The Power of Thinking without Thinking David and Goliath: Underdogs, Misfits, and the Art of Battling Giants Where to get books Check out your local library- many have accounts with online resources, including e-books, audiobooks, etc. Library card required. Overdrive. Access to electronic books and audiobooks from your local library. Audible. $7.95 or 14.95/ month (1-month free trial). Likewise. Find new books, movies, and TV shows based on your favorites. *Follow me to check out my list of recommendations* What Should I Read Next? Enter a book you enjoyed or a favorite author, and find recommendations for other books. Military? You can access magazines, books, videos, newspapers, audiobooks, and random other stuff. First, you need to get an account with an MWR Library. Navigate from the website designated from the MWR resource page, and then save the link for the websites (can't use the generic RBDigital and Overdrive websites). Establish an account and enjoy exploring! MWR Library Resources Online Resources. List of resources- RBDigital, Overdrive, Mango Language service, etc. RBDigital Magazines, e-books, audiobooks, video Overdrive E-books, audiobooks, and videos Mango Language Services. PressReader Newspapers and magazines The Great Courses: Lecture Series. Thousands of lectures on hundreds of topics. Economics and Finance, food and wine, health/ fitness/ nutrition, history, hobby and leisure, literature and language, mathematics, music and fine arts, philosophy, professional and personal development, science, and travel. MWR Library Resources: How-To Access Navigate to: https://mwrlibrary.armybiznet.com . There is a link on this site to the Army MWR Digital Library. “Select your home library below or use the Army MWR Digital Library to search eresources only". You can also go straight to the Army MWR Digital Library page. On the top of the page, click on “find a resource. Click on Ebooks and audiobooks. Under "Overdrive/ Libby"→ click on “access” Verify your eligibility (DODID and DOB)→ you will be sent to the Overdrive website Drop-down “Select your library”→ DOD MWR Libraries Book Reviews Scienceblind Read More Range Read More Everything is Obvious Read More Start with Why Read More Freakanomics Read More Loonshots Read More A Field Guide to Lies Read More Everybody Lies Read More Team of Teams Read More When Read More Black Swan Read More Made to Stick Read More

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< Back Critical Care Resources Society Guidelines CHEST Guidelines. Topics addressed include: Acute Respiratory Distress Syndrome (ARDS), venous thromboembolism (VTE), and liberation from mechanical ventilation. Antithrombotic Therapy for VTE Disease: Executive Summary (2021) SCCM Guidelines. Topics addressed include: Surviving Sepsis, management of pain/ agitation/ delirium, nutrition, critical-illness-related corticosteroid insufficiency, etc. Infectious Disease Society of America. Critical Care Nutrition. Nutrition guidelines and bedside tools (i.e., Nutric score). European Society for Clinical Nutrition and Metabolism (ESPEN). References ICU One Pager. "Critical care education one page at a time. Simple, free, & open source." High-yield clinical topics condensed into single-page reference cards. Other topics addressed in more detail include point of care ultrasound (POCUS) and COVID. The Bottom Line. High-yield journal article summaries focused on the diagnosis and management of critically ill patients. Critical Care Reviews Newsletter. Weekly update on the most up-to-date literature. Register to receive the email weekly. Life in the Fast Lane [LIFTL]. ICU providers provide educational resources for EM and critical care, including EKG interpretation and the Critical Care Compendium. REBEL EM. Journal reviews, tutorials, and other educational tools. Focus is emergency medicine, but plenty of cross-over with critical care. Stanford Critical Care Educational Resources. Free education resources hosted by Stanford Medical School. University of Maryland- Critical Care Project. Critical Care Now. Deranged Physiology. Antibiotic Coverage Diagram [image] EM-Crit Project. Parent website of the Internet Book of Critical Care and PulmCrit. The Internet Book of Critical Care (IBCC) PulmCrit - blog entries on practical ICU topics. Venous thromboembolism and anticoagulation management Anticoagulation Provider Toolkit Anticoagulation Desktop Reference Anticoagulation in Non-valvular Atrial Fibrillation Anticoagulation in Venous Thromboembolism DOAC Bleeding Management Anticoagulation in Pediatric Venous Thromboembolism Periprocedural Management (DOAC) Periprocedural Management (Warfarin) Push-dose vasopressors Push Dose Pressors: Your Quick & Dirty Guide emDOCs: Push-Dose Vasopressors: An Update for 2019 Scott Weingart: Push-dose pressors for immediate blood pressure control Tutorials Edwards Science Clinical Education. Free access to clinical resources including quick references for hemodynamic monitoring and oxygenation assessment of the critically ill. Quick Guide to Cardiopulmonary Care. Hemodynamic Optimization. Perioperative Goal-Directed Therapy. ScVO2 Monitoring. Thromboelastography. Diagrams of TEG and ROTEM, explanation of methods and variables. Previous Next

Goals of Care < Back The person you know her as isn’t there anymore I have used those words on countless occasions while explaining severe/ non-survivable brain injury to patient's families. There are many phrases that providers use to describe end-of-life care. Palliative care. Palliative extubation. Withdrawal of care. Withholding of care.(1) Words are powerful, and conversations about the death of a loved one are remembered well into the future. What they hear can significantly impact their perception of how you are caring for their family or friend. Phrases such as “withdrawing care” can signal that the medical team is giving up and sticking their mother or child or best friend in a dark corner to die a miserable death. We aren’t withdrawing care- in reality, we are continuing to provide maximal patient care, following their wishes. Just because the result is death doesn’t mean we aren’t caring. Death isn’t pretty, and we shouldn’t pretend that we can eliminate the family's pain. But our approach to providing a peaceful dignified death with minimal pain and distress and anxiety can ease some of the family's distress. During my year of dedicated ICU training, I have guided countless families through the decision-making process of end of life care and several conversations will be permanently etched in my memory. I am grateful that I was able to witness and learn from some incredibly experienced and compassionate critical care physicians. While I can’t completely pull back the curtain on the details of these conversations or the specifics of treatment at the end of life, I will share some of the wisdom I gleaned. The patient is already being actively cared for when we have these conversations. Pain and anxiety are treated, bony prominences positioned and patients are turned frequently to prevent pressure wounds. The focus of the conversation is directed at relieving the emotional suffering and distress of the family and friends. Every conversation is different, and empathy and tact are paramount. Also, allowing time for people to express their thoughts is important. It allows them to unload what they are struggling with and also allows the team to tailor the discussion to address their specific concerns. Loved ones present a wide spectrum of emotions. Recognizing and validating these feelings is one way to reassure people that what they are experiencing is not abnormal. It's also a very important step in assessing their understanding of the gravity of the current situation, as well as developing a sense of what their wishes would be (ie mom was very independent and would never want to live like this, my husband writes and teaches, and he wouldn't want to exist if he can't interact in a meaningful way). Some struggle with guilt about unresolved disputes. Others struggle with the crushing sadness of unrealized dreams for their child. But one emotion and concern that is almost universal is guilt about deciding to proceed with comfort care. One such interaction that I will never forget was about the children who were wrestling with the thought of giving up and letting go of their mother who had a devastating brain injury after a car accident. Their respect and love for their mother made it challenging to reconcile with the reality that she wasn’t ever going to be the same person. They talked about how strong and independent she was, and how she would never want to exist in a state of complete dependence. As I sat quietly listening, I heard the words of one of my mentors in my head…”You are showing your love for your mother. This is a gift that you can give her.” We will never erase their feelings, but we can provide reassurance that they aren't inflicting pain and suffering on their family, but they are actually respecting their wishes not to live in this condition. One of the phrases I adopted during my training was “The person you know her (him) as isn’t there anymore.” Seeing flickers of movement, watching their chest rise and fall, and feeling the warmth of their skin can all give hope, that maybe with time and aggressive care, their husband will return to them, their child will wake up and smile at them. The invisible truth of a devastating injury often hides the reality. It is our responsibility and privilege to guide these families through what is likely to be one of the most heart-wrenching moments of their life and to show compassion in our conversation and our care for their loved one. We aren't withdrawing care- we care for our patients until they die, but our goals of care should shift to align with their wishes. Previous Next

< 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

Black Swan The Impact of the Highly Improbable - Silent evidence- you can’t determine causality just by studying the successes. You don’t know the traits of the failures- they could be the same as the successes. Failed writers aren't necessarily bad writers. - The absence of evidence (no evidence of disease) doesn’t mean evidence of absence. - Recognize the unknown unknowns. - Mediocristan (finite limits- weight, height, etc.). Extremistan (boundless- income, book sales, retweets). - The turkey, which is fed every day until thanksgiving, doesn't realize he's getting closer to death. - When a black swan occurs, people rationalize in hindsight and state that it was inevitable. - Series of events preceding a particular situation doesn’t imply causality. We give narratives to make sense of events. - Humans are the victims of an asymmetry in the perception of random events. We attribute our successes to our skills, and our failures to external circumstances outside our control, mainly, to randomness. There is something in us designed to protect our self-esteem. - The law of iterative expectations. If I expect to expect something at some date in the future, I already expect that something now. Stone Age historical thinker is called to write about the events of the era. If he predicts the wheel, then the wheel already exists as a concept. - Different conclusions can be drawn from the same data. Every day you’re alive...you could be closer to death or immortality. Previous Next

< Back Nasogastric Tubes Nasogastric tubes (NGTs) are frequently placed in surgical patients to decompress the stomach and minimize nausea/ vomiting while allowing bowel rest. For intubated ICU patients, this is frequently an orogastric tube, passed from the mouth to the stomach. The anatomy of an NGT Lumen: this is the inner cylindrical hollow conduit that allows gastric contents to be suctioned out and potentially allows medication and nutrition to be given (depending on the clinical situation). Multiple holes to allow gastric contents to be suctioned into the lumen of the tube Side port: if nasogastric tubes were like straws, with only one lumen, they would adhere tightly to the stomach wall when suction was applied. Thankfully, NG tubes have a side port (the blue ventilation port) that allows air to flow into the stomach, preventing the tube from giving the stomach a suction hickey. Markings on the tube indicate how far the tube has been inserted. A white line along the length of the tube (radiopaque). When viewed on an x-ray, the tube position can be confirmed by noting the location of the break in the radio-opaque line, which corresponds with the most proximal hole in the tube. Basic Equipment There is some basic equipment that you need to have at the bedside before inserting an NGT The NG tube and a packet of lubricant A large basin (in case the patient vomits) Suction tubing to connect to a canister with working suction Cup of water with straw (if not contraindicated) Placement Preparation Picking your tube size. Tubes range from 8-18 French. For adults, use 16 or 18. Avoid using a pediatric tube or anything smaller than a 16 Fr. Small tubes will just end up clogged. You can consider having one size smaller just in case you meet a lot of resistance and want to attempt a smaller caliber. Running the tube underwater. Some suggest that warm water helps by making the tube more pliable, others say cold water helps by making the tube softer. I haven't found one to be more helpful than the other. Try and see what works for you. Explain the procedure to the patient. Advise them that they might gag and vomit, and that’s ok. It’s not unexpected when you have a plastic tube through your nose and esophagus. Have the basin ready. Tell the patient their job is to swallow and keep swallowing. Tell them they might feel an urge to cough or gag, but they should try to resist that and focus on swallowing. If not contraindicated (ie aspiration risk, etc), have the patient hold a cup of water (with straw) in the hand opposite from where you're standing. Note- bowel obstruction is not a contraindication- once you place the tube, you will evacuate whatever the patient swallowed. Positioning and insertion Raise the head of the bed and have the patient upright as much as possible and have them put their chin to their chest. Lubricate the end of the tube. Place the tip of the tube just inside the nares and then advance parallel to the floor…not up. You can place your hand on the back of the patient's head to gently keep their head from flying back, which is the natural reaction to a huge piece of plastic in your nose. Keep advancing the tube while encouraging the patient to swallow. The gastroesophageal (GE) junction is usually about 40 cm from the beginning of the esophagus. The tube must get past the GE junction to effectively decompress the stomach. Post-placement Connect your tube to suction. There is a small plastic connector with tapered ends- one end connects to the suction tubing and the other end connects to the clear port. You can place to low intermittent or continuous suction- this is usually provider or institution dependent. You do NOT need a chest x-ray to confirm that an NGT is in the stomach before you place it to suction- if gastric contents are being suctioned, this confirms the position. You DO need a radiograph before instilling medication or enteral feeds. Risks of nasogastric tubes Non-functional tube- an NGT is nothing more than a straw or a garden hose- except for one thing. If you were to place a garden hose into someone's stomach and apply suction, it would just adhere to the stomach wall. This can lead to suction hickeys, which are precursors to ulcers/ bleeding. But most importantly, this will cause the tube to be ineffective. The solution is the blue ventilation port- it allows air to pass into the stomach and keeps the tube from being suctioned against the stomach wall. [this was explained above in the anatomy section- but it's so important that it deserves repetition] Naso-pulmonary tube- accidental insertion into the lung. For an awake interactive patient, this will be evident by your patient's reaction- if they have a tube in their lung, they will cough. This can even cause a pneumothorax (personally never seen it, but it's been described). In an intubated patient, it might not be noticed until x-ray for checking placement. Tube curled and tip directed upward in the esophagus. Two risks- ineffective gastric decompression and misdirected meds and feeds (back up in esophagus instead of into stomach). Aspiration- an NGT essentially stents the lower esophageal sphincter open. So if your patient is lying flat (ie asleep), you MUST ensure that the NGT is functional. Especially in the case of a bowel obstruction (patient can vomit and aspirate) or if your patient has decreased mobility and isn’t able to reposition themselves quickly to avoid aspirating. Clogged tube- risk of aspiration, inability to give meds/ enteral nutrition. The anti-reflux valve You might notice another piece of plastic in the NGT packaging. I didn't mention the anti-reflux valve, that short blue and white plastic piece that suspiciously seems to fit perfectly into the blue ventilation port. According to the manufacturer (CR Bard), this piece of plastic is supposed to be inserted at the end of the blue port and allow air entrainment to prevent the suction hickey on the stomach. It also prevents gastric contents that reflux into the port from spilling onto the sheets. HOWEVER-- the caveat is that when gastric contents are refluxing into the blue ventilation port, it's supposed to be take as an indicator that the valve must be removed and air must be flushed into the blue ventilation port. This is the reason the anti-reflux valves are despised by most surgeons- once the blue ventilation port is coated with gastric contents, if they're not flushed, the NGT is essentially converted to a straw. Yes, the port may spit up some gastric contents. However, the solution is NOT to replace the anti-reflux valve into the blue side port. Instead, the solution is to flush air into the blue port to clear it out . This is the primary task of maintaining a functional tube. You should hear faint sounds of air movement when you listen to the blue port- this means it’s working! [see video] The problem, and the reason we routinely throw these away, is the fact that they aren’t routinely removed and flushed, so they get clogged. When the blue port is clogged, the tube becomes non-functional, which can lead to gastric distension, nausea/ vomiting, and aspiration. “Minimal output” is not always reassuring with an NGT- it might be because the patient is improving, but it’s just as likely that the tube isn’t working because it isn't being maintained correctly. It's not an exaggeration to say this is a life or death issue. An elderly patient with a bowel obstruction and a non-functional tube→ gastric distention + widely patent gastroesophageal junction + laying flat at night→ aspiration, pneumonia, death. Functional tubes are also crucial for patients with foregut procedures. For example, a repair of a stomach or proximal small bowel injury can be protected by a functional nasogastric tube- this minimizes air/ fluid passing by and exerting pressure on the repair. Please note- the blue ventilation port MAY reflux and spill out gastric contents. Two solutions are to place a chux under the end or to place the syringe of a Toomey at the end (see video). Just remember- if this happens, do NOT solve the problem by inserting the anti-reflux valve. Instead, use a Toomey syringe to flush air into the blue ventilation port. CAUTION! There are caveats to this- specifically patients with foregut surgery (anywhere from the mouth through the first part of the small intestine). Patients with these clinical scenarios should have explicit instructions to the nursing staff on how the tubes are to be maintained. But it makes too much noise?! A patient who can complain about a whistling NGT is a patient who is much less likely like to aspirate and need to be intubated than a patient who doesn't have a whistling NGT. But it makes a mess?! See solutions above- chux pad or place a Toomey syringe. How to maintain a functional NGT How to use the anti-reflux valve So those are the basics. If I didn’t teach you any handy tricks, hold on for one last disclosure… the final secret to my success. I've used this trick many times for patients who are overly anxious or distressed at the process of having an NGT placed. For example, the patient who has had traumatic NGT placements previously (patients have shared so many horror stories with me) or is on edge in general. Two years ago, I was managing a burn patient in the ED. While the ED physician was prepping for a nasal laryngoscopy, he showed me a trick that I still use to this day. Using CTAs (cotton tip applicators, or Q-tips if you insist on a brand name), he anesthetized the patient's nasal passage with viscous lidocaine. He covered the cotton tip of 1-2 CTAs with the clear hair-gel consistency goop (the lidocaine), and then slowly advanced this along the nasal passage. Initially, they sat right inside the opening of the nares, resting for maybe 30-45 seconds. Then the lidocaine was reapplied, and the CTAs were advanced slightly to repeat the process. This continued through the entire length of the nasal passage. In addition to the nasal anesthetic, the patient was given a medicine cup with more viscous lidocaine to swallow. *Note- warn the patient that they MIGHT get the sensation that they can't breathe. They will still be able to breathe fine, but when the upper airway is anesthetized, it alters the sensation of airflow. Previous Next

Start with Why How Great Leaders Inspire Everyone to Take Action - Explains the importance of developing a shared philosophy for business, teams, and frankly, any mission. It relays a vital concept, but the text is unnecessarily repetitive- it could be significantly shorter while maintaining the message. - Regarding a business model- your "why" is your basic underlying philosophy, motivation, and guiding principle, your "how" is your process, and your "what" is your product. - You can convince customers to buy your newest product, but you have to re-create your marketing with each novel concept. Loyal customers buy your product because they believe in your philosophy. Think about Apple. They don't sell a product. Apple customers will purchase the next Apple product, not because of the particular design or nuanced update, but because they believe Apple's "why." - Ask an employee or a teammate- what do you do? Is their answer a description of their daily tasks? Or is it a message, a principle that guides their action? - If your company's "what" becomes obsolete, your company becomes outdated. If your company was created to copy written text manually, you would be unlikely to adapt to the new technology that successfully automates the process. If your company's "why" was focused on the value of literature and facilitating easy access to books for everyone, this will allow you to remain relevant regardless of how the world changes. 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

< Back Other Resources Radiology Radiopaedia.org . Open-edit radiology resource, compiled by radiologists and other health professionals from across the globe. How to Read a Chest X-Ray: The Graphic Novel and Drawing Book. Download this “Dummies Guide” to reading chest x-rays and brush up on the basics. Appropriateness Criteria. Evidence-based guidelines to assist providers in making the most appropriate imaging or treatment decision for a specific clinical condition. Acute Right Upper Quadrant Pain Acute Right Lower Quadrant Pain Previous Next

< Back ACS Fellowship Is Acute Care Surgery the right specialty for you? If you are considering a career in Acute Care Surgery, it's important to explore the profession thoroughly before making any decisions. While there are numerous resources available to help you make an informed decision, one of the most valuable resources is speaking with surgeons who currently practice in this field. Experiences can vary widely at different hospitals, so don’t rely on just one opinion. Acute Care Surgery is a challenging specialty that will test you in ways you may never have imagined. It requires a high level of expertise in multiple clinical disciplines. As a surgical critical care fellow, you will face many challenges, such as long working hours, unpredictable workloads managing a mixture of high acuity critically-ill and injured patients, high patient mortality rates, and frequent exposure to severely injured patients. These challenges are not unique to Acute Care Surgery, but they are particularly profound in this field. One of the most significant challenges of this specialty is the emotional toll that it can take on practitioners. Managing patients in the ICU requires a high degree of empathy and compassion, and you will be required to deliver bad news to families and help them navigate difficult decision-making processes. It can be incredibly challenging to witness the suffering of patients and their loved ones, and it's essential to have a good support system in place to help you manage the emotional demands of the job. Despite these challenges, many surgeons find Acute Care Surgery to be an incredibly rewarding profession. Through their work, they have the opportunity to make a significant impact on the lives of their patients and their families. They develop strong relationships with patients and their loved ones, and they have the opportunity to witness the resilience of the human spirit in the face of adversity. If you are considering a career in Acute Care Surgery, it's essential to be well-prepared for the challenges that you will face. Seek out opportunities to speak with surgeons who practice in this field and learn from their experiences. Develop a strong support system that can help you manage the emotional demands of the job, and focus on developing the critical skills that are required to be successful in this challenging and rewarding specialty. With the right preparation and mindset, you can make a significant difference in the lives of your patients and their families as an Acute Care Surgeon. How do I become an Acute Care Surgery fellow? While there are many one-year surgical critical care and two-year trauma/surgical critical care fellowships available, it's important to note that as of 5 October 2020, there were only 28 AAST-approved Acute Care Surgery Fellowships. The application process for these fellowships is centralized through SAFAS . This means that you will need to enter standard personal information, test scores, and personal statements. Additionally, you will need to obtain several letters of recommendation. After you submit your application, programs will contact you if they are interested in offering you an interview. When applying for these fellowships, it's important to cast a wide net and not limit yourself to just a few programs. This may seem daunting if you are applying during your final year of residency, and you are likely already very busy with patient care, managing your team, preparing for board examinations and completing the documentation required for residency completion. Before the COVID pandemic, fellowship interviews were in-person. This was expensive and time-consuming. Virtual interviews may ease this burden, but it’s still a time-consuming process. While you may have a short list of your top choices, I would encourage you to consider a broader range of options. Some programs have online resources that can provide valuable information about the program's strengths and focus areas. When selecting programs, consider your own priorities. Are you looking for a strong critical care focus or a high volume of operative trauma cases? Do you have specific research goals? Fellowship is a short and intense period of focused training to allow you to develop the clinical knowledge and procedural skillset to thrive in this field, so be prepared to commit yourself fully to this opportunity. It's important to note that no program will be a perfect fit for everyone. However, if you approach the application process with an open mind and invest time in your search, you can find a fellowship that sets you on a path towards a fulfilling career in acute care surgery. Helpful Websites AAST ACS Fellowship Applicants . Website with more detailed information about what an Acute Care Surgery Fellowship entails. Approved Acute Care Surgery Fellowships . American Board of Surgery . National organization for board certification in General Surgery, as well as subspecialties including Vascular Surgery, Pediatric Surgery, Surgical Critical Care, Hand Surgery, Surgical Oncology, and Hospice and Palliative Medicine. This is one example of the experience of an ACS fellow at a Level 1 trauma center with a well-organized fellowship program and a well-developed research team. Please refer to " How to get involved " for more information. Clinical Work 12 months of critical care based rotations 8 months of trauma/ surgical critical care (TICU/ SICU) 1 month of cardiac surgical critical care 1 month of medical critical care (MICU) 1 month of Emergency Department Ultrasound training 2 weeks with Nephrology 2 weeks of Research 12 months of surgical rotations 6 months of trauma 3 months of emergency general surgery (EGS) 1 month of transplant surgery 1 month of vascular surgery 1 month of cardiothoracic surgery Research and Publications Two IRB approved research protocols. Lead author on 4 submitted manuscripts. 2 peer-reviewed publications (one as first author). Accepted literature review. Published personal essay. Sub-Investigator on Chest Tube Insertion Trial Author of a book chapter on thoracic trauma management in the ICU Presentations Presented basic science research at AAST Conference Presented process improvement project at department level research symposium Presented a personal essay presented at the EAST conference Nine formal department level lectures. Multiple ICU team lectures. Educational Opportunities Attended operative rib fixation training course Attended training course on IVC filter placement Attended two AAST conferences and one EAST conference Attended critical care/ trauma outcomes committee meetings and trauma morbidity and mortality conferences Attended quality improvement symposium Involvement with local and state trauma advisory committee meetings Previous Next

< Back Ultrasound: Cardiac Exam Purpose: identify possible causes of hemodynamic instability, respiratory distress, assessment of volume status. Probe The phased array can be used for the entire exam. The curvilinear can also be used for the subxiphoid and IVC views. Views There are 4 basic views, including the parasternal long axis, parasternal short axis, the apical four chamber and the subcostal view. Additionally, the inferior vena cava can be visualized. Cardiac ultrasound is more challenging to learn than most other ultrasound studies, because probe usage (position, angle, rotation, translation, etc) have drastic impact on visualization. It’s necessary to understand what is shown in each view, so take time reviewing these so you can have a better appreciation for what you are seeing when you perform a study on a real patient. One recommendation, if it is difficult to visualize the heart, moving the patient into the lateral decubitus with their left side down can significantly improve visualization as the heart is closer to the chest wall in this position. For video and pictorial explanations of the views, please refer to these sites. Basic Cardiac Views, #1 Basic Cardiac Views, #2 Findings Gross abnormalities- decreased ventricular function, arrhythmias Profound hypovolemia Small hyperdynamic left ventricle with end-systolic collapse Inferior vena cava- assess volume status, either static measurement of diameter or calculation of collapsibility (>50% correlates with volume responsiveness). Respiratory variation (collapsibility/distensibility index). Takotsubo cardiomyopathy Akinesia of the apical and mid-ventricular segment, hypercontractile basal segments. Apical sparing (dilated). Acute cor pulmonale Respiratory disorder→ pulmonary hypertension→ right heart failure. Dilated right heart. Cardiac tamponade Effusion with end-diastolic collapse of the right atrium, effusion in front of the aorta Pulmonary embolism Free-floating thrombus in the right ventricle or pulmonary artery; right ventricular dilation/ systolic dysfunction; septal bowing into the left ventricle; dilated IVC without inspiratory collapse. Most sensitive/ specific indirect sign- right ventricular apical sparing (McConnell's sign). References Guidelines for Performing a Comprehensive Transthoracic Echocardiographic Examination in Adults: Recommendations from the American Society of Echocardiography Previous Next