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

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

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

Measuring Cups and Spoons < Back Kitchen Hacks #2 Measuring Cups and Spoons Cooking versus baking…what's the difference? Technically cooking is a general term encompassing all manners of food preparation. But cooking is typically used to indicate a style that doesn't involve baking. Baking is a science that requires attention to detail and precisely measured ingredients that often have to be combined in a specific order. Recipes for baked goods frequently indicate weight in ounces (which required a small countertop scale) as well as volume (measured in your dry measuring cup). On the other hand, cooking allows on-the-fly modifications- it's much more forgiving to small variations. Baking requires precise measurements- so you'll need a variety of dry and wet measuring utensils. If you're unfamiliar with baking, here is a quick summary of how to measure dry and wet ingredients. What are dry measuring cups and how do I use them? These hold the exact amount of an ingredient (you fill these to the top). Either spoon the ingredients into the cup or scoop the cup into the container holding the ingredient (ie wide-mouthed containers). Fill to the top without packing, and level off the top (knife, the handle of a cooking utensil, chopstick, whatever you have). The only ingredient that gets packed is brown sugar- otherwise, unless the recipe specifically mentions packing, don't pack! What are liquid measuring cups or beakers and how do I use them? These have graduated indicators to allow pouring an exact amount of liquid, and the top measurement is below the top of the cup (no spills when pouring). Why can't I just use dry measuring cups for liquids? If you use a dry measuring cup for liquid, it will be very challenging to avoid spilling the ingredient when adding it to the recipe (remember, dry cups get filled to the top). What can I measure with a measuring spoon? Fortunately, these can be used for both dry and wet (although if you have beakers with small measurements, you can also use those for measuring out liquids). Warning about dry ingredients. If a dry ingredient is specified by weight (ounces), this cannot be converted to cups! 8 ounces of flour ≠ 8 fluid ounces of liquid, which is 1 cup of liquid. If you want a visual of the range of what 1 cup of dry ingredients can weigh, check out this extensive list . Previous Next

Practical Tips on Having a Difficult Discussion How Do I Do It? < Back Practical Tips on Having a Difficult Discussion This blog is complementary to the previous blog about becoming more comfortable with uncomfortable conversations. After many difficult discussions with families during my critical care fellowship, I finally became comfortable with uncomfortable conversations. It's impossible to develop a script to use for every conversation, but here are some of the techniques I've adopted over the years. Sit down in a private room, have tissues if appropriate. Make sure your phone/ pager won't interrupt the conversation. Have someone else with you. It’s always good to bring the patient's nurse, and there is often spiritual support staff (ie chaplains) who can accompany you and provide support for the family. Introduce yourself, and ask who everyone in the room is, specifically how they're related to the patient. "Nice to meet you, I'm really sorry it's under these circumstances." If it's your first conversation with the family, it's important to establish a foundation to build on (or establish the absence of a foundation). You can ask "what do you know so far" or "what's your current understanding of the situation"? This also allows them to express their current questions/ concerns. Judge their level of comprehension and adjust as needed. This does NOT mean being patronizing or imposing stereotypes. Pay attention to facial expressions and listen to their questions/ responses. It's easy to fall back into speaking medical jargon- you need to deliberately focus on using easily understandable words. Words that we use every day are meaningless to most people who aren't in the medical field. Keep the conversation brief and take frequent pauses. They don't hear everything you say, and they'll hear even less if you talk non-stop. Allow them time to process what you’ve shared, and allow them to ask any questions they have. Acknowledge that it’s common to be overwhelmed by the discussion. You can validate them by offering "I know I just told you a lot of information" or "I know this can all be overwhelming". It’s also helpful to say, “I’m sure you will think of other questions, please write them down so we can discuss them later” Encourage them to discuss things amongst themselves and provide them a quiet private place to regroup after the meeting. It’s also helpful to say, “I’m sure you will think of other questions, please write them down so we can discuss them later.” This validates their feeling and reassures them that they don't have to worry about remembering every detail. Specific difficult topics - Death and dying. Acknowledge that what they are feeling is normal- regardless of what they feel, it's normal. Denial, angry, scared, guilty, confused, conflicted, exhausted, numb. - When they are wrestling with the decision about transitioning to comfort care (colloquially known as "withdrawal of care", or crassly, "pulling the plug") and they've verbalized that they know it's what their family member would want, acknowledge how difficult that decision can be but also reaffirm that they are doing the kindest thing by honoring their family members wishes. For other helpful tips, check out "Sunburn". "For patients who are alive, concentrate on the ‘big picture’ and avoid the inclination to catalog every injury during this initial encounter. The primary concern in these settings often consists of survival, brain damage, paralyzation and other major morbidities. Again, an overabundance of information can be overwhelming." Velez D et al. SUNBURN: a protocol for delivering bad news in trauma and acute care surgery. Trauma Surg Acute Care Open. 2022 Feb 9;7(1):e000851. Previous Next

14 Scienceblind Why Our Intuitive Theories About the World Are So Often Wrong Intuitive theories- our best guess as to why we observe the events we do and how we can intervene in those events to change them. Infer causality from our observations. Similar to historical theories- how we used to understand things before we had the ability to understand the reality (like heat as an “object” versus “energy”). Emergent process- system wide (no clear cause/ effect explanation), equilibrium-seeking, simultaneous, ongoing. Heat, weather, evolution are all emergent processes. Molecular theory, scientific theory. Holistic theory- matter is continuous and has heft and bulk Intuitive theories of the physical world Matter- substances are holistic and discrete, instead of particulate and divisible. Conservation- clay flattened, water poured from short fat glass to tall skinny glass. The difference between weight and heft, volume and bulk? Energy- heat, light and sound viewed as substance instead of emergent property. Why can you touch the 400 degree air in the oven but not the pan itself (without oven mitts)? The pan transfers heat better than air. How do we change from viewing “sound” as an “object” to viewing it as “energy”? First, we stop attributing permanence (noise doesn’t continue forever), then weight (clock doesn’t become lighter with each chime) and then mass (noise can pass through a wall, doesn’t have to maneuver around wall). Extra-missionist- rays go out of the eye and then return to create vision vs intro-missionist- rays enter the eye to create vision. Gravity- weight is an intrinsic property of objects instead of relation between mass and gravity. Objects don’t fall because they’re heavy- they fall when they don’t have upward force on them that exceeds gravity (center of gravity). Motion- force is something transferred between objections (“impetus”), instead of external factor changing the objects motion. What path will an object take- for example, a ball in a spiral slide- takes straight path after exiting, doesn’t gain an inherent “spiral” motion. Cosmos- earth is a motionless plane orbited by the sun. Changing of the tides, seasons (tilt of the earth as it revolves around the sun, the side closest to the sun is summer). Earth- continents and mountains are eternal and unchanging vs transient/ dynamic. Tectonic plates- similar land features on different coasts. Greenhouse effect and global warming- humans causing it, but the earth will live beyond us. Vitalism- living things possess an internal energy, or life force, that allows those things to move and to grow. Essentialism is the idea that an organism’s outward appearance and behavior are products of its inner nature, or “essence.” Intuitive theories of the biological world Life- animals viewed as psychological agents vs organic machines. Death= cessation of biological processes. Growth- eating is for satiation rather than nourishment, aging is a series of discrete changes vs continuous change. Vitalism- living things possess an internal energy, or life force, that allows those things to move and to grow. Essentialism is the idea that an organism’s outward appearance and behavior are products of its inner nature, or “essence.” Inheritance- parent-offspring resemblance viewed as nurture, vs transfer of genetic information. Illness- disease is due to supernatural causes, instead of microorganisms. Adaptation- evolution is the transformation of an entire population (butterflies become slightly darker with each generation) vs selective survival (darker butterflies survive to reproduce). Ancestry- species develop linearly (monkey→ ape→ human) rather than branching from common ancestor. Previous Next

11 Made to Stick Why Some Ideas Survive and Others Die 6 Principles of Sticky Ideas - Simple - Unexpected- crash at the end of the car commercial. - Concrete - Credibility- the ability to test. Before you vote ask yourself if you are better off today than you were 4 years ago- Reagan. - Emotions - Stories Curse of knowledge- we find it hard to imagine not knowing what we have learned. Can’t imagine what it’s like not to understand a certain concept that we accept as fact Previous Next

< Back Machete Attack- Neck Trauma A 42-year-old male was brought from an outside hospital after sustaining deep, extensive penetrating wounds to the neck and forearms. When he arrived at the hospital, we noted defensive wounds on his forearms and a deep laceration across the anterior neck. The report from EMS was that the patient was assaulted with a machete. What are the management priorities? Prioritize primary and secondary survey and treat life-threatening injuries first. Don't be distracted with impressive wounds. Secure the airway and control active hemorrhage. He was initially seen at a small community hospital, where an endotracheal tube was placed through the tracheal wound, and then he was transferred to our facility. He was rapidly transported to the operating room for evaluation. What structures need to be evaluated? Vascular structures (carotid arteries, vertebral arteries, jugular veins) and upper airway/ digestive structures (esophagus, pharynx). The head and neck team was consulted, and they evaluated him in the operating room. The wound's extent was explored thoroughly. Surprisingly, there were no injuries to the vascular structures, and the injury was isolated to the airway. The endotracheal tube was exchanged for a formal tracheostomy and a stent was placed in the upper airway to prevent luminal narrowing while the repair healed. The wound was closed in layers. Management of Penetrating Neck Trauma WTA Algorithm Anatomy Zone 1 Clavicles/ sternum to cricoid Zone 2 Cricoid to angle of mandible Zone 3 Angle of the mandible to the skull base Hard signs- airway compromise, massive subcutaneous emphysema/air bubbling through the wound, expanding or pulsatile hematoma/ active bleeding, shock, neurologic deficit, hematemesis. Soft signs- hemoptysis, blood in the oropharynx, dyspnea, dysphagia, dysphonia, subcutaneous air, chest tube air leak, non-expanding hematoma, bruit/ thrill. Hard signs or hemodynamic instability→ ensure airway and transport to OR. No immediate operative indications? Depends on symptoms and the zone of injury. Zone 1 and 3- CTA to rule out vascular and aerodigestive injuries; assess the trajectory of injury. Injury→ repair. Concerning trajectory→ triple endoscopy (laryngoscopy, bronchoscopy, and esophagoscopy). Zone 2- symptomatic→ OR. Asymptomatic- serial exams or imaging. Operative approach The most common incision for exploration of neck wounds is along the anterior border of the sternocleidomastoid (SCM) muscle. Exposure of Zone 1 and 3 are more challenging and endovascular adjuncts are useful. Zone 1 may require median sternotomy with extension along the SCM. Zone 3 requires mobilization of the mandible. Zone 2 can be approached with a transverse cervical collar incision with SCM extension. - Tracheal injuries are repaired with monofilament absorbable suture. - Esophageal injury- debride unhealthy edges, ensure full exposure of mucosal defect, repair defect (single or double layer), buttress with SCM, or strap muscle. Place drain. - Combined tracheoesophageal injury- repair, and ensure repairs are isolated with interposition of a well-vascularized muscle flap. Previous Next

< Back Getting Involved Getting involved in your training program and hospital is crucial for your professional development and growth. Here are some tips to help you get started. - Be open to opportunities to get involved early and embrace small projects. Even if a project seems insignificant, it can lead to bigger opportunities. Don't hesitate to accept requests to help write a paper, design a research protocol, or participate in a committee. These small projects can open doors for more significant roles and responsibilities in the future. - Be proactive and take the initiative to get involved. Talk to your mentors and program directors about your interest in participating in projects or committees. Ask for guidance on how to get involved, and don't be afraid to express your interest in specific areas. - Get involved in research. You don’t have to have a strong research background to contribute to ongoing projects. If you have specific research interests, seek the advice of someone with a similar interest and collaborate with them. Different faculty members will have their individual strengths and passions, which are frequently apparent after you interact with them. If you partner up with someone who has a similar interest, they will be able to guide you and lend their support to your project. Training programs frequently have requirements for research and have a framework for supporting involvement in ongoing projects. Research requirements are often a part of training programs, so take advantage of the support and resources available to you. Also, keep in mind that there may be ongoing research projects at your hospital that you can contribute to. - Attend department and hospital level conferences. Grand rounds, morbidity and mortality (M&M) and case conferences are invaluable learning opportunities. Conferences that review complications or deaths are invaluable learning opportunities. They are also a good platform for developing performance improvement projects. Many patient incidents are multifactorial, and there are frequently systems issues that can be addressed to minimize repeat events. - Join committees. Committees are a great way to learn about the inner workings of the hospital and contribute to important decision-making processes. They also provide a venue to meet colleagues in other departments and gain valuable networking experience. - Talk to people. Reach out to your mentors, program directors, and research staff about other opportunities that may be available. They can often provide valuable insight and connections that can lead to new opportunities and projects. After you have explored the opportunities to get involved in your program and hospital, it’s time to widen your professional network. Expanding beyond your hospital will help you stay current with industry trends, discover new opportunities, and establish relationships with colleagues and mentors. One way to do this is by participating in surgical organizations at the national level. Here are some examples: - American College of Surgeons (ACS). The ACS offers membership and participation opportunities starting in medical school. As a member, you can take advantage of educational programs, networking events, and leadership development opportunities. Fellowship in the ACS (FACS) requires board certification, and it is a prestigious recognition that can enhance your professional reputation. - American Association for the Surgery of Trauma (AAST). AAST is the premier national organization for the field of acute care surgery (trauma, surgical critical care and emergency general surgery). There are numerous opportunities for involvement in research and professional development. Membership requires FACS status. However, the organization recently added an associate membership category, which offers younger surgeons an opportunity to participate in the AAST's activities and programs. - The Eastern Association for the Surgery of Trauma (EAST). EAST provides leadership and development opportunities for young surgeons who are actively involved in the care of injured patients. The organization offers ample opportunities to get involved in committees, research projects, mentorship, and leadership roles. This is far from an exhaustive list, but it is a good starting point for young surgeons to explore how they want to develop their network. During my Acute Care Surgery fellowship, I was able to get involved in various research projects and initiatives that allowed me to further develop my expertise and knowledge in the field. At the start of my fellowship, I developed a research protocol that evaluated the impact of legislation on the opiate epidemic. This project allowed me to delve into a critical issue facing the healthcare industry and explore potential solutions to mitigate the epidemic's impact. Shortly after, I attended a department committee that updated our clinical practice guidelines. As we discussed some recent patients with rib fractures, I saw the importance of updating our thoracic trauma management guidelines. I partnered with one of the faculty who had a particular focus on rib fracture management and we worked to optimize our protocol for caring for these patients. This led to multiple opportunities, including an IRB protocol and two manuscript submissions on operative rib fixation. I also had the opportunity to co-author a book chapter on Intensive Care Unit (ICU) management of blunt chest trauma and a manuscript on the use of opiates in chest trauma. During a meeting with one of the research directors in our department, I was able to learn about opportunities to get involved in ongoing projects. This led to me joining a group working on coagulopathy in traumatic brain injury. Through this project, I was able to contribute to a literature review submission and co-author a research manuscript submission. I was also able to present our findings at a national conference. My program director was a strong supporter of and actively shared news about opportunities that could further my career development. One of these opportunities included writing an essay that allowed me to publish and present at a conference. After reading my essay, a critical care physician reached out to connect and invited me to participate in testing a tool for resuscitation in austere environments. This was a unique opportunity that allowed me to apply my knowledge and skills in a new and challenging setting. Overall, my Acute Care Surgery fellowship allowed me to explore different avenues in research and develop expertise in areas that I am passionate about. It also enabled me to collaborate with other experts in the field, broaden my network, and gain invaluable experiences that served me well in my future career endeavors. Previous Next

Overcoming barriers while teaching and being humble as a consultant Tackling the expertise bias < Back Overcoming barriers while teaching and being humble as a consultant Why is it so hard to remember what it was like before you knew the things that you now consider fundamental, basic knowledge? If you are a teacher, which includes school teachers as well as everyone responsible for passing knowledge to others, self-reflection on how you relay information and assess comprehension is paramount. One common challenge is overcoming the "curse of knowledge". The curse of knowledge takes hold and becomes a hurdle when the teacher/ instructor assumes that their audience has the same background knowledge and should be "up to speed" without significant delay. In other words, there are many things you do every day that you consider obvious and second nature. It is exceedingly easy to be quick to judge your trainees for not recalling or readily grasping those concepts. How has this manifested itself in my experience as a teacher in the ICU? Caring for patients with a wide breadth of physiologic derangements is a rich environment for interactive real-time learning. Invasive mechanical ventilation is a perfect opportunity to learn about respiratory physiology. Learning how to pick the right mode/ settings and how to make adjustments to optimize each patient's oxygenation and ventilation (while avoiding further lung injury) is key to good critical care for the patient that requires respiratory support. My understanding of mechanical ventilation was the culmination of many hours and long months/ years spent reading, preparing lectures, tinkering bedside with ventilators, engaging in dialogue with experts, and just immersing myself in the weeds. At some point, and I have no idea when it was precisely, it finally clicked. I didn't become an omniscient guru. But after enough practice, the fundamental concepts finally became solidified in my mind, and managing ventilators has become second nature. Ventilator management is a cornerstone of ICU care. Whenever there are patients that require ventilation beyond perioperative indications, I capitalize on the opportunity to teach. Even though I'm acutely aware of how much work (seemingly endless hours of work) went into learning the finer points of ventilators, it's still hard to remember what it was like before I understood. Please note- this phenomenon is NOT limited to in-person teaching. This barrier can infiltrate lectures, manuscript writing, and a variety of other forms of communication and interaction. Another situation relevant to the medical profession- the consultation with a specialist. If you're on the receiving end of the consult, it can be easy to fall into the trap of assuming everyone should have the same knowledge you have. It's crucial to remember that you are an expert in YOUR field- if the physician calling you had the same knowledge, you would be obsolete. So how do you overcome this hurdle? Here are my suggestions 1. The first step is to acknowledge that your interactions can be impacted by your bias. You know more than your students, or the person that's calling you for a consult. More specifically, you know more about what you're teaching your student and you know more about the clinical situation than the person consulting you. That's why you're the teacher and the consultant. 2. Take time to reflect on how you interact when teaching- do you rapidly become impatient, roll your eyes, reply with condescension or snark, or simply look at your students like they're idiots? Pause in real-time: it doesn't have to be awkward, and I'm sure your audience will appreciate a moment to pause and think. 3. Take the opportunity to put the shoe on the other foot. Reflect on what it was like when you were learning- as an intern struggling to remember how to replete electrolytes, a young resident in the ICU struggling to understand ventilators, or even a young attending struggling in a high-stress operative case. How would you want to be approached/ treated? Previous Next

< Back Pancreatitis UpToDate Patient Education Patient education: Acute pancreatitis (Beyond the Basics) Patient education: ERCP (endoscopic retrograde cholangiopancreatography) (Beyond the Basics) Source: UpToDate Images: Pancreas Anatomy Previous Next

< Back Pain and Anxiety...pending Management of Pain and Anxiety Previous Next