8 Freakanomics A Rogue Economist Explores the Hidden Side of Everything - Hard to include all the different topics under one umbrella. Very controversial topics, such as crime, cheating, the impact of a name. - Correlation versus causation. Does legalized abortion lead to decreased crime? Using broad generalizations, people who grow up with mothers who didn't want them are placed in circumstances that increased their likelihood of involvement in crime. Previous Next

13 Maybe you Should Talk to Someone A Therapist, HER Therapist, and Our Lives Revealed Some of my favorite quotes Peace. It does not mean to be in a place where there is no noise, trouble or hard work. It means to be in the midst of these things and still be calm in your heart. (p. 289). HMH Books. Kindle Edition. “Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom. (p. 289). HMH Books. Kindle Edition. Which is why, in the end, after several drafts and revisions, Julie decided to keep her obituary simple: “For every single day of her thirty-five years,” she wanted it to read, “Julie Callahan Blue was loved.” Love wins. (p. 313). HMH Books. Kindle Edition. Previous Next

< Back Sausage Tortellini and Brussels Sprouts Ingredients Sausage Tortellini 2 Tbsp olive oil 2 lbs sausage 2 cloves garlic, minced 1 c vegetable broth 2 c tomato sauce ½ c heavy cream 18 oz tortellini Salt & pepper Brussels Sprouts One package of Brussels Sprouts olive oil black pepper sea salt balsamic vinegar Instructions Sausage Tortellini Heat oil in a large skillet and cook sausage links about 5-7 minutes, until sausages are browned throughout. Add garlic and heat for 30 seconds. Remove sausages from skillet and slice into bite-size pieces. Return sausages to pan along with broth, tomato sauce, cream, and tortellini. Season with salt & pepper. Cover and simmer for 12 minutes. Brussels Sprouts Prepare sprouts by trimming the base and then cutting the sprouts in half or quarters, and then place them in a medium-sized bowl. Drizzle a small amount of olive oil and balsalmic vinegar, and then sprinkle black pepper and sea salt. Toss to coat the sprouts, let sit for at least 30 min. Roast at 400 for 20-30 min, toss halfway through. Sausages cooking Previous Tortellini in Sauce Brussels Sprouts Next

< Back Electrolytes...pending Electrolyte Management Previous Next

< Back Anal Fissure What is an anal fissure? Patient information: Anal fissure [American College of Colon and Rectal Surgeons] Patient education: Anal fissure (Beyond the Basics) [UpToDate] Trauma from hard stool (constipation) creates a tear in the anoderm distal to the dentate line. Pain leads to internal sphincter spasm, setting up a vicious cycle! Symptoms- severe pain during and immediately following a bowel movement ("like pooping glass", "passing a razor blade"), blood on toilet paper with wiping. This often leads to fear of having bowel movements. Pain leads to muscle spasm→ higher pressure→ vicious cycle. Diagnosis- classic history is almost enough, but pain with effacement of the buttocks and visualization of a tear in the anoderm confirms. Don’t torture them with a digital rectal exam! On exam, typically seen in the posterior midline. If a fissure is seen in a different location, consider IBD, trauma, infection (Tuberculosis, sexually transmitted diseases), cancer. Source: UpToDate Images: Anal Fissure Anatomy What is conservative management for an anal fissure? See “ Anorectal Disease: How do I prevent anorectal disease? ” Improving bowel habits is the first-line treatment for an anal fissure. See patient handouts below. The majority of patients with an acute fissure heal with conservative management. If a fissure has been present for a long time, it is less likely to heal with conservative therapy. Sitz baths- fill a tube with water as warm as you can tolerate, and soak your bottom after every bowel movement and at least 3 times per day. Topical compounds- nitrates, calcium channel blockers→ relax muscle→ improved blood flow→ allows healing. Local anesthetics can also improve symptoms during the healing process. Avoid suppositories, Tucks pads, and Preparation H. These would be painful and won’t treat the disease. This is why diagnosis is vital. Patient Info- Anal Fissure .pdf Download PDF • 59KB Patient Info- Fiber Guide .pdf Download PDF • 68KB What is the operative management for an anal fissure? For the few patients who fail a trial of conservative therapy, surgical intervention can provide relief. Botulinum toxin (Botox) blocks neuromuscular function leading to muscle relaxation. Yes, this is the same Botox that is used to treat wrinkles. Low risk of complications. Lateral internal sphincterotomy is the treatment of choice for chronic fissures that have failed to resolve with other interventions. More successful healing compared to other interventions. Risk of incontinence (inability to control the passage of gas and stool). If incontinence occurs, the inability to control gas is more common than the inability to control liquid stool, which is more common than the inability to control solid stool. Previous Next

< Back Vent Mgmt #1: Basics The goal of ventilatory support is to maintain appropriate O2 and CO2 in the blood while offloading the work of the respiratory muscles and minimizing iatrogenic lung damage. Understanding this principle will help guide your ventilator management. Many variables can be manipulated on the ventilator, but there are a few key variables that truly control oxygenation and ventilation. While there is not one ideal setting for every scenario, there are a few basic principles that cover the majority of ventilator management. Basic Ventilator Settings First, it is important to understand what the ventilator does. The ventilator can push air into patients. You can control how much air is pushed in (tidal volume), the number of breaths per minute (respiratory rate, RR), and the concentration of oxygen molecules in the air itself (fraction of inspired oxygen, FiO2). It's also possible to control how quickly air is pushed in (flow)- but we will get to that later. It is important to note: the ventilator does NOT generate pressure- it only monitors pressure to prevent damage from elevated pressures (barotrauma). Breathing is controlled by three variables. Trigger- this determines when a breath starts. Either time, flow, or pressure. Time trigger is utilized when the patient is not generating any spontaneous breathing (ie mandatory breaths). Flow and pressure triggers are utilized if the patient has spontaneous respiratory activity. When the patient attempts to inhale, there is a change in flow and/ or pressure. This is sensed by the ventilator, and a breath is delivered. Limit- this sets the maximum value a parameter can reach during a breath. For example, volume-limited indicates that a breath can't exceed a certain max mL and pressure-limited indicates that the pressure monitored by the machine can't exceed a certain max cm H2O. For a graphic representation, please refer to the image in the section on Limit Variables in Deranged Physiology. Limits impact the shape of the waveform. Volume limited- flow ceases when the set/ target volume is delivered. Pressure limited- a large portion of the TV delivered at the beginning of the breath until the set/ target pressure is reached and then the flow tapers, slowly delivering the remainder of the volume until the breath is time or flow cycled (see next) Cycle- this determines the end of a breath. Time cycled- inspiration ceases at the end of a set time duration. Used in mandatory breaths. Flow cycled- inspiration ceases when flow drops below a certain level. Used in spontaneous breaths. Volume and pressure are not currently used to cycle breaths. The goals of mechanical ventilatory support are O2 delivery (oxygenation) and CO2 removal (ventilation). Effective oxygenation and ventilation are measured by an arterial blood gas- PaO2 indicates the partial pressure of O2 and PaCO2 indicates the partial pressure of CO2. Oxygenation is a function of the concentration of O2 delivered to the patient (fraction of inspired O2, FiO2) and the surface available for O2 exchange. Positive pressure maintains open airways, which maintains the surface available for O2 exchange. Mean airway pressure (MAP) is the parameter that indicates the average pressure measured in the lungs throughout inspiration (inspiratory pressure) and expiration (positive end expiratory pressure, PEEP). Expiration is usually 2-3 times longer than inspiration, so MAP is often simplified to PEEP when trying to optimize oxygenation. However, increasing inspiratory time can improve MAP without adjusting PEEP. Ventilation is controlled by minute ventilation (total volume of air exchanged every minute). Minute ventilation is respiratory rate multiplied by tidal volume. Therefore, respiratory rate (RR) and tidal volume (TV) are the two parameters that can optimize ventilation. Lung-Protective Ventilation Minimizing iatrogenic lung injury is also important when caring for patients receiving ventilatory support. Different types of trauma, including barotrauma (excess pressure), volutrauma (excess volume), and atelectrauma (repetitive opening and closing of alveoli), can damage lungs that are already diseased. The risk of barotrauma can be minimized by monitoring airway pressures (peak and plateau pressures). Volutrauma can be minimized by low tidal volume. Historically, larger tidal volumes were standard (10-12 mL/kg). Currently, the most commonly recommended volume is 6-8 mL/kg (there are some exceptions). Decreased TV leads to ↓minute ventilation and ↓CO2 clearance (↑PaCO2). This is the basic physiologic principle behind "permissive hypercapnia" during mechanical ventilation for ARDS. Atelectrauma can be minimized by maintaining PEEP, which keeps alveoli open. Additional References 1. Respiratory Therapy Pocket Reference Card Previous Next

< Back Hemorrhoids What are hemorrhoids? Patient information: Hemorrhoids [American College of Colon and Rectal Surgeons] Patient education: Hemorrhoids (Beyond the Basics) [UpToDate] Hemorrhoids are a normal part of anorectal anatomy. They are blood vessels in the end of the rectum and at the anal verge. External hemorrhoids overlie the external anal sphincter (at the anal verge) and the internal hemorrhoids overlie the internal anal sphincter (inside the rectum). The hemorrhoids fill with blood and help maintain continence (avoid leaking stool). See images below. Anything that increases pressure in the abdomen, including prolonged straining, coughing, pregnancy, and an enlarged prostate requiring straining to urinate, can lead to abnormally large venous plexuses, which are what most people know as hemorrhoids. Internal hemorrhoids are lined by the same tissue as the rest of the GI tract, which secretes mucus. External hemorrhoids are lined by the same tissue as the rest of the skin on our bodies. Source: UpToDate Images: Internal and External Hemorrhoids Symptoms When hemorrhoids become abnormally large as a result of prolonged straining, typically from constipation, they can cause pain and bleeding. Internal hemorrhoids- dull/ achy pain and bleeding with bowel movements. In addition, if internal hemorrhoids prolapse (move from inside the rectum out onto the perianal skin), which typically occurs with bowel movements, this can cause issues with perianal moisture, itching and skin irritation. This is caused by the mucus from the overlying tissue. Prolapsed hemorrhoids can sometimes reduce spontaneously (return to their normal location in the rectum) or might require manual reduction (might have to be pushed back in after having a bowel movement). If internal hemorrhoids External hemorrhoids- bleeding with bowel movements. Acute pain can occur when an external hemorrhoid becomes thrombosed (acutely filled with blood clot→ overlying skin gets stretched→ severe pain). What is conservative management for hemorrhoids? See “ Anorectal Disease: How do I prevent anorectal disease? ” Improving bowel habits is the first-line treatment for hemorrhoids. See patient handouts below. Sitz baths- fill a tube with water as warm as you can tolerate, and soak your bottom after every bowel movement and at least 3 times per day. For itching: moisture in the perianal skin can cause itching. Improving bowel habits and gentle perianal skin hygiene can improve this. Zinc oxide can be used as a topical barrier twice daily. For protruding or swollen internal hemorrhoids: hold the hemorrhoid tissue with a Tucks pads (witch hazel) to decrease the swelling, allowing the hemorrhoid tissue to be reduced. Patient Info- Hemorrhoids .pdf Download PDF • 58KB Patient Info- Fiber Guide .pdf Download PDF • 68KB What is the operative management of hemorrhoids? Acute thrombosis of external hemorrhoids- most patients will have resolution of symptoms with conservative management described above. However, if you present within the first 48-72 hours, the hemorrhoid can be excised. Incision and drainage alone is not recommended, given high rates of recurrence. If symptoms have been present for more than 72 hours, surgery is more likely to create more discomfort, and therefore it is typically avoided. Large external hemorrhoids or mixed internal and external hemorrhoids with prolapse- typically managed with hemorrhoidectomy or hemorrhoidopexy. Internal hemorrhoids- banding is the most common treatment. Other options include sclerotherapy and infrared coagulation. Previous Next

< Back More Information on Acute Care Surgery The Beginnings of Acute Care Surgery: A Paradigm Shift in Surgical Emergencies. Nelson BV and Talboy GE. Acute Care Surgery: Redefining the General Surgeon. Mo Med. Sep-Oct 2010;107(5):313-315. Acute Care Surgery from the perspective of acute care surgeons. Santry HP et al. A qualitative analysis of acute care surgery in the United States: It’s more than just “a competent surgeon with a sharp knife and a willing attitude.” Surgery. 2014 May;155(5):809–825. A detailed timeline of our history. The AAST History of Acute Care Surgery . Previous Next

< Back Gallbladder Disease Cholecystectomy (gallbladder removal) is one of the most common operative procedures performed. What does the gallbladder do? Your gallbladder stores bile and enzymes from the liver. When you eat, your gallbladder squeezes to drain bile into the intestines to help you digest food. What are the reasons for cholecystectomy? Symptomatic cholelithiasis. If gallstones are present, they can lead to increased pressure and pain when the gallbladder contracts. Typically occurs with a fatty meal. Pain can last minutes to hours. Acute cholecystitis. When the gallbladder drainage is blocked by gallstones, it can become acutely inflamed. Symptoms are similar to symptomatic cholelithiasis, but the symptoms don't resolve. Source: UpToDate Images: Anatomy of the Gallbladder What does surgery entail? What are the risks of the procedure? Your gallbladder is under your liver. Laparoscopic surgery is typically done with an incision at your belly button and 3 incisions under your ribs on the right upper abdomen. There is a risk of pain, bleeding, and infection with any surgical procedure. Specific to this procedure, there is a risk of damage to surrounding organs, including the liver and intestines. The worst-case scenario is damage to the tube that drains from the liver into the small intestine, called the common bile duct. This complication is infrequent, but if it occurs, you will need more procedures and a longer hospital stay. If we can't see things safely laparoscopically, we will proceed with an open incision under your ribs on the right. This is not common with elective surgery and is more likely in elderly diabetic patients with acute severe inflammation. *IOC- there is an additional procedure that we will perform that shows us the bile ducts and allows us to see if there are any stones in the bile duct that can cause obstruction. 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. UpToDate Patient Education Patient education: Gallstones (Beyond the Basics) Patient Information from Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Gallbladder Removal Surgery (Cholecystectomy) American College of Surgeons Operation Brochures Cholecystectomy: Surgical Removal of the Gallbladder 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

< Back ICU Society of Critical Care Medicine (SCCM): Patient and Family Resources Meet the Critical Care Team Learn about the members of the ICU care team. Patient Communicator Application This free app by SCCM is designed to improve communication between patients, families, and caregivers. Critical Care FAQs Learn about which patients require care in the ICU, what things commonly happen in the ICU, as well as find a more detailed explanation of common medical conditions seen in the ICU. Resource Library The MyICUCare.org Resource Library includes complimentary materials aimed at educating patients and families about the critical care journal, both during an ICU stay and after discharge. Understanding Your ICU Stay: Information and Patients and Families booklet. American Thoracic Society- Patient Education | INFORMATION SERIES Managing the Intensive Care Unit (ICU) Experience: A Proactive Guide for Patients and Families Mechanical Ventilation What is Acute Respiratory Distress Syndrome? What is ECMO? Central Venous Catheter Arterial Catheterization What is Hemodialysis for Acute Kidney Failure? What is Sepsis? Palliative Care for People with Respiratory Disease or Critical Illness Tracheostomy in Adults Living with a Tracheostomy Venous Thromboembolism- Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) Preventing Venous Thromboembolism [John Hopkins Medicine: Armstrong Institute for Patient Safety and Quality ] Previous Next

10 Loonshots How to Nurture the Crazy Ideas That Win Wars, Cure Diseases, and Transform Industries - S type and P type loonshots. Innovators (creating loonshots) have to co-exist with the “businessmen”- you can’t just segregate different groups. The innovators need the company to make a profit so they can continue to take risks and make discoveries. And the business needs to nurture loonshots. - In case you were wondering how polarizing crystals were discovered. Or check out this article in Science magazine. - Bad decisions may occasionally result in good outcomes. But you need to analyze wins- you might not be so lucky next time. - Good decisions may result in bad outcomes. You made the best decision with the information at your disposal. In those same circumstances, you’d make that same decision. - How do crickets synchronize their chirps? - Percolation. A mathematical explanation for predicting events based on an inherent variable. - How do forest fires spread? Relevant variables- the distance between trees, humidity, wind. - How do pandemics start? How appropriate…depends on the proximity of individuals. - Phase transitions - Why do traffic jams occur? Just above a certain density of cars on the roads→ jam. - Emergence- innate characteristics of how a group functions based on the size (ie what patterns shift after the group reaches a size, although the precise size is variable for groups) While individuals remain puzzles, man in the aggregate becomes a mathematical certainty. Meaning- group dynamics are universal, regardless of the characteristics of the group members. Previous Next