< Back Common Conditions Trauma and ICU Patient education: Preventing infection in people with impaired spleen function (Beyond the Basics) For patients who have had their spleen removed (typically related to trauma) Patient education: Pulmonary embolism (Beyond the Basics) Also known as a blood clot in the lung or PE. Disclaimer from UpToDate (included at the end of every patient handout) [This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circumstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof. The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms ©2022 UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.] Previous Next

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

< Back What happens during Surgical ICU (SICU) Rounds? This does NOT reflect the practice pattern of every SICU. All the components must be addressed, but there are many variations on how they are incorporated into the daily routine. Flash Rounds A multi-disciplinary process that includes the charge nurse, respiratory therapist, clinical nutritionist, physical therapists/ occupational therapists, clinical case manager, and a senior member of the team (attending, fellow, APP). Focused on ensuring that each patient has daily goals and a plan from each of the team members, ensuring that key issues are addressed early instead of waiting until after rounds (nutrition, plans for ventilator weaning, disposition planning, etc.). Working Rounds A multi-professional process that includes the bedside nurse, "learners" (broad term to include students, residents, advanced practice provider (APP) fellows), as well as the APPs (nurse practitioners (NP) and physicians assistants (PA)) and a clinical pharmacist. The team is led by the attending physician or critical care fellow. Engagement and communication by all team members are encouraged. After reviewing overnight events, a system-based approach is used to methodically evaluate the patient's current clinical status and then develop a management plan. 1. Systems-Based Rounds- presented by resident or APP - Neurologic- assessment of mental status, including the Glasgow Coma Scale (GCS), Richmond Agitation-Sedation Scale (RASS), etc. Current sedation and analgesia regimen. Review relevant radiologic imaging. - Cardiovascular- relevant vital signs and hemodynamic monitoring parameters, including trends and ranges. Review current cardioactive medication. - Pulmonary- current ventilator settings, relevant laboratory values (arterial blood gas), relevant radiologic imaging (chest radiograph). - Gastrointestinal- physical exam. Assess nutritional status (tolerating enteral nutrition, contraindication for enteral feeds, plan for parenteral nutrition). Review relevant radiologic imaging (abdominal radiograph). - Genitourinary/ Renal- review intake/ output (I/Os). The total volume of fluid intake (intravenous fluids, nutrition, blood, antibiotics, etc.) and fluid output (urine, stool, drains, etc.). Relevant laboratory values (basic metabolic panel). - Endocrine- review glycemic control. - Hematology- assessment of coagulation status or abnormal blood counts (hemoglobin, platelets). - Infectious Disease- physical exam- fever and evaluation of all possible infection sources (catheters, wounds, respiratory secretions). Review relevant laboratory values (white blood cell count, culture results), review current antibiotic therapy. - Prophylaxis- review needs for venous thromboembolism and stress ulcer prophylaxis. 2. A-F Bundle presentation by bedside nurse [SCCM ICU Liberation Bundle] - Assess, prevent, and manage pain - Breathing (Spontaneous awakening and breathing trials) - Choice of analgesia and sedation - Delirium assessment, prevention, and management - Early mobility and exercise - Family engagement 3. Develop a management plan based on comprehensive patient assessment. 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

General Surgery Lectures General Surgery .pdf Download PDF • 152.12MB Anorectal .pdf Download PDF • 1.55MB CT Scan and X-ray .pdf Download PDF • 564KB Vascular .pdf Download PDF • 13.57MB Suture .pdf Download PDF • 4.94MB

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

< Back Acute Care Surgery Clinical Guidelines EAST Practice Management Guidelines. Evidence-based guidelines developed and published by EAST. Covers EGS, ICU, trauma, and injury prevention. SurgicalCriticalCare.Net . Evidence-based guidelines from Orlando Regional Medical Center. Vanderbilt Trauma and Surgical Critical Care Practice Management Guidelines. Evidence-based guidelines developed by Vanderbilt. Covers trauma and surgical critical care topics. Evidence-Based Decisions in Surgery. This does require membership with the American College of Surgeons. General Medical Information UpToDate. The name says it all- evidence-based recommendations based on the most current literature. Subscription required. Previous Next

< Back Mentorship What is mentorship? Mentorship is a partnership between a more experienced and knowledgeable individual (mentor) and a less experienced individual (mentee) seeking to learn, develop skills, and advance their career in the healthcare profession. The mentor is typically someone who has achieved a level of success that the mentee aspires to reach. Through this relationship, the mentee, who could be a medical student, trainee (resident or fellow), or junior staff member, can benefit from the mentor's expertise and past experiences, gaining valuable insights into the healthcare profession. The mentor can serve as an advisor, consultant, or coach depending on the mentor's expertise and the mentee's needs. For example, a mentorship relationship can be designed to help the mentee improve clinical skills, navigate the job search process, or advance research endeavors. It's common to have different mentors for different purposes, as each mentor may have different strengths. Mentorship also provides networking opportunities, as the mentor can facilitate connections between the mentee and other professionals in the field. In summary, mentorship is a valuable tool for professional development in healthcare, offering guidance, support, and connections that can help mentees achieve their goals. Do I really need a mentor? Throughout medical school and residency, I didn't have any formal mentors, but I did actively seek the opinions, advice, and feedback of several surgeons I respected. As a young staff surgeon, I still didn't actively pursue mentorship, though I now recognize that it could have been highly beneficial. My first formal mentorship relationship was late in my training, when I was an Acute Care Surgery fellow and I was required to choose a staff member as a mentor. It's not uncommon for trainees to lack mentors, and one possible explanation resonates with me. "Many young people today who end up in residency…have been on a fast track. They’re essentially high-achieving, highly driven professional students who have been on a fairly regimented pathway…and they haven’t reached a point where there are multiple pathways they could take."(1) As someone who has been on a straight path since high school, progressing from high school to medical school to residency to being a junior faculty, I potentially missed out on a valuable asset. It's important to note that having a mentor is not a requirement, but developing a strong relationship with a mentor can positively influence one's success. It's highly recommended that individuals consider formal mentorship, but it's equally important to recognize that they have the ability to end relationships that are toxic or not a good fit. How do I find a mentor? Mentorship relationships can be an essential aspect of professional growth for medical trainees. These relationships can develop organically or be assigned by program directors in residency or fellowship programs. If you are assigned a mentor, it can be a great experience, but it is also possible that you may not mesh well if the assignment was not carefully considered. It's essential to recognize that if you find yourself in a mentor-mentee relationship that is not productive, amicable, or beneficial, it's okay to end the relationship and seek out another mentor. On the other hand, organic mentorship relationships can also be incredibly fruitful. As you work with various individuals in different settings, such as the operating room, during rounds, or while discussing consults, you will begin to form opinions and may find that you gravitate towards a particular person. If you respect and trust them and they demonstrate skills or expertise that you want to learn from, they might be a viable option as a mentor. The process of finding a mentor can be as simple as asking the person you would like to work with if they would be willing to mentor you. Remember, the worst they can do is say no, so it's worth taking the risk to ask. If they don't have the time to commit to being a mentor, they may be able to connect you with someone else who could be a good fit. It's important to recognize that mentorship relationships require effort from both the mentor and the mentee. While your mentor can offer guidance, support, and feedback, it's ultimately up to you to take ownership of your own professional development. Be clear about your goals, seek out feedback, and be receptive to constructive criticism. By putting in the work, you can make the most of your mentorship relationship and set yourself up for success in your career. Finding a mentor can be a great way to help you achieve your personal and professional goals, but it's important to have a plan in place to make the most of the relationship. Here are some steps you can take after finding a mentor to ensure that you get the most out of the relationship: 1. Set specific goals: Take some time to think about what you hope to gain from your mentorship. Are you looking to improve your skills in a particular area? Do you want help navigating a career transition? By setting specific goals, you can make sure that you and your mentor are on the same page and working towards the same objectives. 2. Establish communication: Once you've set your goals, it's important to establish how you will communicate with your mentor and how frequently you will meet. This can be done through formal meetings, phone calls, or casual chats over coffee. Make sure that both you and your mentor are comfortable with the frequency and type of communication. 3. Complete assignments or tasks: Your mentor may assign you tasks or provide you with guidance on specific projects. It's important to take these assignments seriously and complete them as directed. This could be anything from revising your CV to drafting a study protocol. By following through on these tasks, you can demonstrate your commitment to the mentorship and make progress towards your goals. 4. Reassess and refine: As you work with your mentor, it's important to regularly reassess your progress and refine your goals. This may involve checking off completed tasks, adding new objectives, or removing items that are no longer a priority. By keeping your goals current and relevant, you can make sure that you are making the most of the mentorship. Overall, finding a mentor can be an incredibly valuable experience. By taking the time to set goals, establish communication, complete assignments, and reassess your progress, you can make sure that you get the most out of the relationship and achieve your personal and professional objectives. 1. Darves B. Physician Mentorship: Why It’s Important, and How to Find and Sustain Relationships. NEJM Career Center. 2018 Feb. 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

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

< Back Before Surgery American College of Surgeons (ACS) Operation Brochures for Patients Patient Education: Preparing for Your Surgery How Can I Be Strong for Surgery? Strong for Surgery is a program that works with surgeons and hospitals to provide tools like checklists that surgeons can use to assess your risks in four target areas: nutrition, blood sugar control, smoking cessation, and medications. You can lower your risk by being better prepared for your operation. NSQIP Surgical Risk Calculator Disclaimer: The ACS NSQIP Surgical Risk Calculator estimates the chance of an unfavorable outcome (such as a complication or death) after surgery. The risk is estimated based upon information the patient gives to the healthcare provider about prior health history. The estimates are calculated using data from a large number of patients who had a surgical procedure similar to the one the patient may have. Previous Next

< 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. 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