< Back Unusual Case of Peritonitis A 23-year-old male presents to the ED with several days of abdominal pain. He is otherwise healthy and denies any other symptoms. On exam, he has diffuse peritonitis, but no other obvious findings. He is tachycardic with a heart rate in the 110s-120s. His blood pressure is 100s/60s. No significant medical or surgical history. No remarkable events recently. He had plain films of his chest and abdomen. Plain film of the chest and upper abdomen What's going on? Differential diagnosis? Perforated hollow viscus- gastric or duodenal ulcer, bowel obstruction leading to perforation, procedural complication (EGD, ERCP). On further questioning, the patient endorses a recent soccer game during which he blocked a goal and was hit in the stomach. Unsure if it was the soccer ball or a kick to the stomach. He then had a CT of his abdomen and pelvis. CT of the abdomen and pelvis, representative slices What's going on? Diagnosis? Intervention? Free air (pneumoperitoneum) and free fluid are consistent with a perforated hollow viscus. No clear source on the CT. This requires abdominal exploration. We proceeded with exploratory laparotomy. Found liters of succus. There was a single perforation of the small bowel that was resected and anastomosis was performed. The abdomen was closed and a drain was placed. Intraoperative Findings Management of Peritonitis from Perforated Hollow Viscus The hollow viscus refers to the gastrointestinal tract from the esophagus to the rectum. Pain associated with hollow viscus perforation is classically acute onset, constant, severe, and worse with movement. The peritoneal lining of the abdomen becomes inflamed in reaction to the leaking enteric contents. This is a surgical emergency. The diagnosis can be made with the visualization of pneumoperitoneum on an upright chest x-ray (lucency under the diaphragm). A patient with peritonitis and free air requires surgical exploration. A CT scan can help identify the underlying pathology, but is not mandatory and should not delay operative intervention. Non-operative management is reserved for the patient with a sealed perforation (example- retroperitoneal duodenum) or a patient who is a prohibitively high-risk operative candidate (example- patient on palliative or hospice care). Cultural differences Not all cultures have adopted the practice of Western medicine. In some cultures, people still seek advice and medical care from traditional healers. Unfortunately, this can delay treatment if a patient requires operative intervention. Some of the treatments provided by traditional healers can also lead to further injury. This patient with a small bowel injury was seen by a traditional healer several times before he was finally brought to the hospital. The marks on his skin are the result of a practice of cutting the skin to heal the cause of his abdominal pain. Another patient was brought to the hospital for a severe infection of his genitalia. By the time he came to the hospital, his infection was so extensive that he required a debridement of a large portion of the skin in his perineum. He had been seeing a healer who was treating him with a topical solution that had essentially burned his skin, so in addition to the underlying infection, he had severe tissue damage. Previous Next

Common Measurement Conversions < Back Kitchen Hacks #3 Common Measurement Conversions Powdered Milk Reconstitution Use volume of water equivalent to desired milk volume. 1 Cup Milk= 3 Tbsp Powdered Milk= 45 mL 3/4 Cup Milk = 2.25 Tbsp Powdered Milk 2/3 Cup Milk = 2 Tbsp Powdered Milk= 30 mL 1/2 Cup Milk = 1.5 Tbsp Powdered Milk 1/3 Cup Milk = 1 Tbsp Powdered Milk= 15 mL 1/4 Cup Milk = 3/4 Tbsp Powdered Milk Measuring Spoon Conversions 1/2 tsp= 2.5 mL 1 tsp= 5 mL 1 + 1/2 tsp= 1/2 Tbsp= 7.5 mL 2 tsp= 10 mL 3 tsp= 1 Tbsp 6 tsp= 2 Tbsp= 1/8 c Liquid Measurement Conversions 1 fluid ounce= 2 Tbsp= 6 tsp 2 fluids ounces= 4 Tbsp= 1/4 cup 2+2/3 fluid ounces= 5 Tbsp + 1 tsp= 1/3 cup 4 fluid ounces= 8 Tbsp= 1/2 cup 6 fluid ounces= 3/4 cup 8 fluid ounces= 1 cup 16 fluid ounces= 2 cups= 1 pint 4 cups= 2 pints= 1 quart 4 quarts= 1 gallon Substitute dry for fresh spices 1:3 of dry:fresh 1 tsp dry= 1 Tbsp fresh Previous Next

< Back Chicken Enchiladas in Sour Cream Sauce Ingredients 10 small soft flour tortillas 3 Tbsp flour 2 c chicken broth 1 c sour cream 2.5 c shredded cooked chicken 3 c shredded Monterey Jack cheese 3 Tbsp butter 4 oz can diced green chillies Instructions 1. Preheat oven to 350 degrees 2. Combine shredded chicken and 1 cup of cheese. Fill tortillas with the mixture above and roll each one then place in a greased 9x13 pan. 3. Melt butter in a pan over medium heat. Stir flour into butter and whisk for 1 minute over heat. 4. Add broth and whisk together. Cook over heat until it's thick and bubbles up 5. Take off heat and add in sour cream and chilies. Be careful it's not too hot or the sour cream will curdle. 6. Pour mixture over enchiladas and add remaining cheese to top. 7. Bake in oven for 20-23 minutes then you will want to broil for 3 minutes to brown the cheese. The roux, with sour cream and green chilies added Previous Enchiladas covered with sauce Cooked and broiled to brown the cheese Next

3 < 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 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 Vent Mgmt #5: Weaning When is the patient ready to start ventilator weaning? Resolution of pathology resulting in the need for mechanical ventilation Able to assess mental status (ie can the patient follow commands) Hemodynamics and respiratory physiology is optimized (ie ABG normalized or returned to patients baseline, and normalization or stabilization of cardiac function) Minimal ventilator settings (FiO2 21%, PEEP 5) NOTE: Even if there is no immediate plan to extubate, sedation holiday and spontaneous breathing trials should still be performed [unless there are specific contraindications] Spontaneous breathing trial Spontaneous mode of ventilation (such as pressure support or CPAP) with 5-8 cm H2O support during inspiration (basically overcoming the force required to breath through the small diameter of the ETT) Failing SBT Hemodynamic instability (hypotension or hypertension, tachycardia or bradycardia) Agitation Respiratory instability (hypoxia, inadequate tidal volume, tachypnea or decreased respiratory rate) Extubation parameters- how do we know if the patient is ready to be liberated from the ventilator? Able to generate adequate minute ventilation Rapid shallow breathing index (RSBI)- RR/ TV. High respiratory rate (rapid) and low tidal volume (shallow) are more suggestive that a patient isn't appropriate for extubation. Value <105 suggests the patient will successfully extubate. This is also known as the Tobin index.[1] Negative inspiratory force (NIF)- the patient's ability to generate negative pressure with inhalation. Cuff leak- ability to move air around the endotracheal tube. Not mandatory to evaluate for cuff leak prior to extubate EXCEPT for patients is at high risk for airway edema (traumatic intubation, intubated >6 days, large ETT, female, reintubation after unplanned extubation). Reasons for failed ventilator weaning Prolonged hospitalization and associated weakness Hypophosphatemia Primary process requiring mechanical ventilation is unresolved Passed SBT...but failed ventilator liberation? Excess secretions/ inability to cough Cardiac instability related to physiological changes with loss of positive pressure (specifically decrease in intra-thoracic pressure leading to decreased cardiac output) Tobin Index. Yang KL, Tobin MJ. A Prospective Study of Indexes Predicting the Outcome of Trials of Weaning from Mechanical Ventilation. N Engl J Med. 1991 May 23;324(21):1445-50. Previous Next

Gadgets and Tools < Back My Favorite Things Gadgets and Tools Packing and Travel These Hopsooken packing cubes make organizing your suitcase a breeze. These noise-canceling headphones effectively drown out the rumbling noise of airplanes at a reasonable price. The Patagonia Black Hole Duffel . Multiple sizes available. Very spacious. Easily converts to a backpack when traveling for easy carrying. Therma-Rest compressible pillow from REI Quick Dry Towel from REI Cleaning Products Goo Gone - for removal of excess sticky residue. Greased Lighting - great for stain removal. It can be purchased at Lowes/ Home Depot. Kitchen Storage containers for baking ingredients. These wide-mouthed containers let you pour baking ingredients from their original bags with minimal mess. It’s also very easy to use a scoop directly into the containers when baking. This is a perfect bread box ! When I leave a loaf of bread in its original package, it gets moldy pretty quick- but if I put it in this box, it lasts much longer. Bakers Rack . My current kitchen has much less cabinet space than what I have grown accustomed to, so I sought out a solution to store my baking supplies that take up my counter space. Now my bread maker, mixing bowls, large metal colander, and rolling pin no longer hide above the fridge or clutter my counters. Writing Accessories A hand-held non-electronic datebook . After years of relying on electronic resources to maintain my schedule, I finally made the switch to a device that allows me to create/ maintain a schedule, both weekly and monthly formats. Also has blank pages at the back, perfect for lists, notes, etc. Frixion Erasable pens “We've all had a shower thought or two…They're the miniature epiphanies that occur when your brain is occupied with doing something else, but suddenly you realize that you've come up with a totally unique way of thinking.” And sadly, once we step out of the shower, the great idea seems to vanish. Thankfully, someone developed this notepaper that doesn’t fall apart in the shower! A roll of self-adhesive whiteboard paper to post to your wall, your fridge, your mirror, wherever. Handy in the kitchen- plan meals, add items to put on your grocery list when you discover you’re running low or just write reminders. My favorite highlighters when writing notes. They aren’t too heavy, so they don’t bleed or run. They are dual-tipped, with a broad highlighter on one end and a narrower tip for writing on the other end. My favorite pen . Fine tip to allow precise, small writing. Trello - a user-friendly free application with multiple functions. I use it to store frequently used documents to allow quick reference. It is also a very convenient way to create and manage lists among teams so everyone has easy access. Check it out, you might find it useful. Things for the Ladies I don’t wear many thin garments or revealing necklines, so I don’t often have to struggle to find a bra that remains concealed. However, on the rare occasion that I wear a dress or top that isn't conducive to wearing a bra, these reuseable cover-ups are incredibly handy for maintaining decency. If you're interested in making the transition from disposable monthly products, check out this product . This is the only one I've tried, so I can’t compare them, but it's worked well for me. Lume Deodorant . Doesn’t stop sweating, but eliminates odor. Highly highly recommend. If you find yourself having to unclog the shower drain with clumps of hair, you might want to check out the Tub Shroom . Previous Next

< Back GI Dysmotility...pending GI Dysfunction Previous Next

1 Trauma Lectures Ab Vasc Exposure .pdf Download PDF • 1.04MB DCR and MTP .pdf Download PDF • 42.86MB Burn .pdf Download PDF • 4.67MB Thoracic Trauma .pdf Download PDF • 69.57MB US in the Military .pdf Download PDF • 15.25MB

Life and Death Decisions in a Resource-Constrained Environment Blood Shortage < Back Life and Death Decisions in a Resource-Constrained Environment When resources aren't in short supply, patient care isn’t limited by access to resources. As we quickly noticed at the beginning of the COVID-19 pandemic, nationwide supply shortages can develop quickly. In addition to the continuously growing staff and supply shortage the nation is currently enduring, we now have a critical shortage of blood products. The categories of patients who receive blood transfusions are diverse, and my colleagues and I use this resource daily. So I'm going to ask the uncomfortable question. Have you ever been in a resource-limited environment where you were unable to provide every patient with the same level of care? Have you ever been in a difficult position to allocate supplies and medical care based on triage? And most recently, have you been forced to re-evaluate your transfusion practice in light of this severe blood shortage? Several months ago I had a tragic case of a young male who suffered penetrating abdominal and pelvic trauma. He had multiple injuries to his IVC, his right iliac as well as hollow viscus injuries. I had another trauma attending, a trauma fellow, and a chief resident in the operating room. We were simultaneously working in multiple body cavities. Initially, I was holding manual proximal aortic control at the diaphragmatic hiatus. This was modified to transthoracic aortic cross-clamp, which also permitted open cardiac massage. Unfortunately, despite 4 educated pairs of hands, the patient remained hemodynamically tenuous. We cross-clamped the aorta and continued aggressive blood product resuscitation. I lost track of how many products he received, but it was likely one of the highest volumes I've ever given a patient. I'm a young staff surgeon, and this was the first case where I was faced with the ethical dilemma of withholding further transfusion in the setting of surgical futility. He had injuries that we were working to control, and in isolation, each injury was easily survivable. However, he sustained a constellation of symptoms too severe to tolerate. Whenever the thoracic aortic cross-clamp was released, he became profoundly unstable. Inability to tolerate the removal of cross-clamp is incompatible with life. No one wants to be seen as giving up, admitting failure, or abandoning a patient. As I gain more experience, I become increasingly comfortable with uncomfortable situations. In the back of my mind, as each minute passed, I became progressively more cognizant of the fact that the patient's mortality was inevitable. I didn't verbalize this until much later in the case. But at one point in the case, when I heard the number of units of blood transfused, my sense that the patient was unlikely to survive became overwhelming. I was grateful to have a colleague with me to openly discuss the conflict of continuing to administer blood products in a patient with essentially 100% mortality. We are charged with caring for patients with the same level of care, indiscriminately- not withholding interventions based on our judgments of a patient's worthiness. Blood products are an extremely precious and limited resource, and shouldn't be used without thoughtful consideration. Verbalizing that continuing resuscitative efforts while a patient is still alive is not without consequence. There are people in the room who don’t have the same experience, who don’t understand that even though we can continue to fix injuries, further use of blood products would not help the patient. By extension, there could be a patient who needed blood to save their love who could be deprived access to that resource. It takes experience to make these difficult calls. So how do you gain this wisdom and how do you handle these situations? - You only gain this wisdom through experience. It can’t be taught, it can only be learned by facing similar situations. - Remember you're not working in isolation. You don’t have to make the decision alone. Enlist the support of colleagues and senior partners. - Verbalize your thoughts- this makes others in the room aware of the current clinical situation. This also can empower team members to offer suggestions. In challenging clinical situations, I commonly say "does anyone else have any ideas". Some teammates do not feel comfortable speaking up in a room of physicians/ surgeons, so this can open the floor for a frank discussion. Previous Next

< Back Appendicitis What is appendicitis? The appendix is a small worm-like structure that hangs from where the small and large bowel connect in your right lower abdomen. It can become inflamed and cause pain. What does surgery entail? What are the risks of the procedure? The surgery to remove your appendix involves using a camera and thin instruments. We typically make 3 incisions- one at your belly button, one right above your pubic bone and one in the left lower abdomen. We divide the appendix with a stapler and remove it. You’ll have a foley in your bladder to help get your bladder out of the way because one of the ports is placed right over the bladder. The folly goes in after you go to sleep and is removed before you wake up. It might burn the first time you pee after surgery. There is a risk of infection following an appendectomy. Bacteria live in the appendix and when we divide it, the bacteria can fall out and form an abscess. This risk is higher if your appendix is ruptured at the time of surgery. This typically presents very similar to appendicitis, because it’s an infection in the same part of your abdomen. Most of the time that can be managed without surgery. We can have our radiology colleagues place a drain into the abscess cavity. What can I expect post-operatively? You will have several small incisions from the laparoscopic port sites. They will have absorbable sutures, nothing that needs to be removed. You will have glue or gauze and paper tape on the incisions. The glue will peel off on its own in 10-14 days. If you have gauze, you can remove this in two days and shower like normal. You will have paper tape strips on the incision, and these will peel off on their own. You are at risk for a hernia through the small incisions, so avoid heavy lifting for 4 weeks after surgery. You may take acetaminophen (Tylenol) and ibuprofen (Motrin) as needed for pain. These can be taken at the same time. Take the narcotic pain medication if your pain is severe despite the acetaminophen and ibuprofen. After the few first days, you should work on decreasing the number of narcotics that you are taking. What can I eat after surgery? There are no specific dietary restrictions. However, if you eat a fatty meal, it may cause loose stool (diarrhea) until your body adjusts to not having your gallbladder, which previously stored the chemicals used to digest fatty food. This is seen in about 10% of patients and usually resolves. If it lasts more than a few weeks, there are medication options to treat this. What should I be worried about after surgery? If you have fever >101 F, severe nausea/ vomiting, inability to tolerate liquids, severe abdominal pain, increasing redness, or drainage from your incisions. Patient Information from Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Appendix Removal (Appendectomy) Surgery American College of Surgeons Appendectomy: Surgical Removal of the Appendix Previous Next

< Back C dificle Colitis...pending Management of Clostridium Difficle Colitis Previous Next