< Back Postoperative hypotension A 35-year-old male is in the ICU following emergency surgery for a small bowel obstruction. On arrival to the ICU, he has the following vital signs: HR 115, BP 85/40, SpO2 98. He underwent a 4-hour open lysis of adhesions. He received 2L of crystalloid and made 50 mL of dark urine, and did not require any medication to improve his blood pressure. He remains intubated and sedated. What is the differential for his hypotension? Hypovolemia- under-resuscitation relative to the insensible losses from open abdomen and likely preoperative dehydration Sepsis- bacteremia from gut translocation from small bowel obstruction, pneumonia from aspiration due to obstruction Tamponade, tension pneumothorax- did he have any intra-vascular devices placed in the OR? Pulmonary embolism- lengthy surgery, did he have appropriate mechanical prophylaxis? Cardiomyopathy The surgical team reports that he has not been tolerating a diet, or even liquids, for the previous 3 days. He received perioperative ertapenem for surgical infection prophylaxis. There was no evidence of aspiration during intubation and his admission CXR was unremarkable. He had a right internal jugular central line placed intra-operatively. He had no issues with oxygenation/ ventilation or high airway pressures intra-operatively. How can you diagnose shock and differentiate between the different potential etiologies? Physical exam- evaluation of skin turgor/ color/ temperature and mucous membranes, evaluation of fluid status (open wounds, nasogastric tube output, passive leg raise), examination of urine quality, auscultation of heart/ lungs Labs- cultures, complete blood count, lactate, liver function tests, BUN/Cr Ultrasound- gross evaluation of heart function, lung sliding to rule out pneumothorax, volume and collapsibility of the inferior vena cava Test for fluid responsiveness- based on stroke volume variation (SVV, see below), or response to passive leg raise or a fluid challenge. On exam, he is tachycardic without murmurs, lungs have equal air movement bilaterally. His nasogastric tube remains on suction with ongoing high output of gastric contents. On ultrasound, he has bilateral lung sliding. His cardiac contractility looks grossly preserved. He has normal oxygenation. His inferior vena cava is collapsible. He has a known source of infection (positive blood cultures), leukocytosis, elevated lactate, high fluid losses with evidence of fluid responsiveness. Shock: Undifferentiated Hypotension Hypotension ≠ shock. So what is shock? Inadequate perfusion to maintain end-organ function Pathophysiology: effective perfusion requires adequate cardiac output (CO). CO is the volume of blood that the heart pumps each minute, and it depends on stroke volume (SV; the volume of blood ejected with each heartbeat) and heart rate (HR; the number of heartbeats per minute). SV depends on preload (intra-vascular volume returning to the heart), myocardial contractility, and afterload (systemic vascular resistance). Shock is a disruption of preload, contractility, and/ or afterload. Signs of shock= signs of end-organ hypoperfusion Altered mental status (brain) Decreased urine output (kidney) Change in color/ temperature of extremities (skin) Abnormal liver function tests (liver) Ileus (gastrointestinal tract) Diagnosis of shock + tools for monitoring response to treatment Elevated lactate (global hypoperfusion) Ultrasound- evaluate cardiac function, evaluated IVC to assess volume status Minimally invasive cardiac monitoring (central line or arterial line)- CVP and SVV to assess volume status Invasive cardiac monitoring (pulmonary artery catheter)- cardiac output, ScVO2 (central venous oxygen saturation) Four types of shock Shock is typically categorized as hypovolemic, obstructive, cardiogenic or distributive. However, in order to link the specific category with the associated pathophysiology, I have described each state as it relates to maintaining cardiac output, as described above. Decreased preload: hypovolemic shock- low circulating blood volume→ decreased blood volume returning to the heart. Etiologies: bleeding, inadequate fluid replacement/ maintenance, high output from nasogastric tube or ostomy, insensible losses that aren't appropriately replaced (burn patients, large open wounds). Decreased preload: obstructive shock- disease process that impedes venous return to the heart (tamponade, tension pneumothorax, pulmonary embolism). Decreased contractility: cardiogenic shock- disturbance of the intrinsic function of the heart. Etiologies: heart failure, arrhythmias, valvular insufficiency, or decompensated valvular stenosis. Decreased afterload: distributive shock- dilated peripheral vasculature, sometimes known as vasoplegia. Etiologies: sepsis, anaphylaxis, neurogenic following spinal cord injury (NOTE- this is NOT the same as spinal shock), burns, trauma, pancreatitis. Neurogenic- hypotension with concurrent bradycardia. Vasoplegia is a term used to describe pathologically low systemic vascular resistance- this can be associated with post-cardiac bypass or any of the other causes mentioned here. Management of shock Treat underlying cause (see below). Restore adequate intravascular volume (aka preload). This is part of the initial treatment of hypovolemic shock, obstructive shock, and distributive shock. Fluids in the management of cardiogenic shock depend on the primary cardiac pathology. Treat hypotension/ decreased cardiac output that persists despite fluid resuscitation and treatment of the underlying cause. Septic shock- norepinephrine is the first line vasoactive medication. Monitor end-points of resuscitation (see above, Diagnosis of shock + tools for monitoring response to treatment ) Supportive care- nutrition, respiratory support, venous thromboembolism, etc. Specific Treatments Based on Etiology Hypovolemia from hemorrhage- transfusion, stop the bleeding Hypovolemia from fluid losses- replace fluid via enteral or intravenous route, as appropriate Sepsis- antibiotics, control source of infection (appendectomy, drain placement, etc). Tamponade- drainage of pericardial fluid (pericardiocentesis, pericardial window) Tension pneumothorax- release of tension physiology (needle decompression or finger thoracostomy) Cardiogenic- management of primary cardiac pathology, whether that entails treating acutely decompensated heart failure, resolving acute symptomatic arrhythmias, etc. Previous Next

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

Stereotype of a Surgeon Heartless with a God Complex < Back Stereotype of a Surgeon Abrasive, intimidating, self-confident, egotistic, stubborn, arrogant, difficult to work with, aggressive, competitive, and domineering, technically masterful, astute, energetic, and precise.(1) These are just a few of the adjectives that have been used to describe surgeons. The top Google autocompletes for the phrase "why are surgeons…” include arrogant, rough, rude, important, jerks, mean, cold, weird. There is a balancing act between the need to demonstrate confidence while maintaining our humanity and our humility. We wield sharp instruments, and we ask our patients to trust us to fix them while they lay naked and exposed, anesthetized, and vulnerable. So how do we reconcile these seemingly opposing characteristics? How do we show strength, leadership, and confidence in our decision-making and skills and also develop a rapport with patients and families? How do we show our patients that we will be with them to celebrate their recovery and stand by them in the face of complications and setbacks in their recovery? Effective communication is key to relationship building. In general, surgeons are not known for their stereotype that surgeons don't have the best bedside manner. "As a group, surgeons are not well known for their bedside manner."(2) We (usually) operate on completely unresponsive patients, so the stereotype that we don’t like talking to patients is not illogical. This stereotype extends to anesthesiologists. While this is a satirical representation, there is a kernel of truth in the idea that most don’t go into specialties that frequent the OR to spend MORE time talking to patients. "While poor manners aren't commonly accepted in most professional circles, representations of surgeons in popular culture often link technical prowess with rude behavior, and some surgeons have even argued that insensitivity can be helpful in such an emotionally strenuous profession."(2) I probably spend more time talking to patients and their families than the typical surgeon. I find these personal interactions to be truly remarkable. During my training, I developed my style for communication. When I share information with a patient and their family, I treat them as if it were my family member. Based on my perception of their interest in detail and my direct explanation that I will share as much or as little as they like, I tailor my interaction with each new encounter. I believe in full disclosure, including admitting when I don’t have the answers. My training has given me the confidence to admit when I need more information or plan to consult with a colleague. Some might see my willingness to admit imperfections as a sign of weakness. While I didn’t develop my practice regarding disclosure with the express intention of avoiding legal consequences, poor communication and lack of empathy are commonly cited in malpractice suits.(3) So besides the intrinsic benefit of developing respectful interactions with patients, the extrinsic factor of avoiding the courtroom is powerful. A study published in 2019 found that surgeons are regarded as high in warmth and competence, relative to other non-medical occupational groups,(4) in contrast with the stereotype that we lack social skills. The study also noted that female surgeons received higher warmth ratings than male surgeons, while male surgeons received higher competence ratings than female surgeons. It is not an easy task, but building trust with our patients requires us to instill confidence while maintaining our humanity. 1. Logghe HJ. History of Medicine: The Evolving Surgeon Image. AMA J Ethics. 2018;20(5):492-500. 2. Neilson S. When Surgeons Are Abrasive To Co-Workers, Patients' Health May Suffer. 2019 Jun. NPR. 3. Huntington B. Communication gaffes: a root cause of malpractice claims. BUMC Proceeding. 2003;16:157–161. 4. Ashton-James CE. Stereotypes about surgeon warmth and competence: The role of surgeon gender. PLoS ONE 14(2): e0211890. Previous Next

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

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

Confessions of an ICU Physician with a terrible memory Accessing the Right Information < Back Confessions of an ICU Physician with a terrible memory Training in medicine starts with textbook learning. But the art of caring for patients can’t be learned in a textbook. Higher-order thinking is essential to understand the interaction between multiple conflicting disease processes, identify nuisances of atypical presentations and find solutions for clinical conundrums. As the field of medicine grows exponentially, the volume of information is too much for one person to keep track of. I find that understanding clinical concepts is much easier than rote memorization of pharmaceutical brand names with their associated generic name, recalling the dose of a paralytic, or identifying the ideal antibiotic for a multi-drug resistant bacteria. After several years of learning and studying mechanical ventilation and how it interacts with and affects a patient's respiratory physiology, I now understand the principles of how to optimize oxygenation and ventilation. As an ICU physician, I can't re-read the basic textbook of mechanical ventilation every time I care for a patient with respiratory failure. I must be able to make decisions relatively quickly and must be able to explain my rationale to residents and bedside nurses while we are working to manage a patient with severe lung disease. But I can pause to look up the recommended dosing of a medication for a patient on dialysis or identify the best anti-microbial for a particular bacteria or fungi. What do I do about important information that I need immediate access to but that doesn't reside in the forefront of my mind? Smartphones, with access to websites and applications , have revolutionized our ability to bring evidence-based medicine to the bedside. Clinical practice guidelines can be accessed on society websites. Deployed Medicine is a resource that provides access to Tactical Combat Casualty Care and Joint Trauma System Clinical Practice Guidelines. There are apps for a wide number of clinical programs that were initially web-based, such as UpToDate. In addition to the resources that are openly available to the public, I have created a database of personal high-yield references. Medication dose ranges, CPGs for our trauma center, AAST Injury Scales, sedation/ pain scores, TEG parameters, and a wide variety of other information that I refer to on a relatively routine basis are now in the palm of my hand. I use the Trello app. I created a dedicated workspace with a group of lists (titles such as trauma, medication, ICU, etc) which each contain multiple individual cards (titles such as A-F bundle, CAM-ICU/ RASS/ CPOT, TEG). I'm not saying you have to use this. But I highly recommend finding a tool that works for you. TL;DR • Take the time to understand processes and concepts- learn one physiology concept from each pt • Have an external tool for storing “rote memorization” facts that you can readily access Previous Next

< Back Pneumonia...pending Pneumonia Previous Next

< Back Respiratory Failure- it hurts to breathe A 47-year-old male sustains multiple traumatic injuries after being struck by a vehicle while on the side of the road. He had severe thoracic trauma (bilateral pulmonary contusions), bilateral femur fractures and a liver laceration. He also had a severe TBI, requring intubation shortly after his arrival. 10 days into his hospital stay, he still requires ventilatory support. What are some of the potential causes of the patients ongoing requirement for mechanical ventilatory support? Pain from rib fractures, pneumonia, ARDS, pulmonary embolism, fat embolism, pulmonary contusions, loss of chest wall stability due to severe thoracic trauma, hypomagnesemia, volume overload, retained hemothorax, poor nutrition from inadequate protein delivery. He is undergoing a trial of spontaneous ventilation, but he develops tachypnea and hypoxemia and appears to be struggling on the ventilator. What are some of the initial steps in evaluating this patient? Physical exam (pulmonary exam, assess for edema), bedside ultrasound (pleural effusion, pneumothorax). Chest x-ray- look for infiltrates. ABG, EKG, review volume status. His chest x-ray is shown below. What do you see? Trachea midline, no effusions. Bilateral fluffy infiltrates. His current ventilator settings and ABG results are shown below. Ventilator settings: RR 12, TV 450, PEEP 10, FiO2 50. Arterial blood gas: pH 7.34, PaCO2 42, PaO2 64, HCO3 24 What does this tell you about his oxygenation? PaO2:FiO2 ratio is an indicator of oxygenation. This patients P:F ratio is 182. See below for explanation. What diagnosis is this consistent with? Acute respiratory distress syndrome. What are the management principles when caring for a patient with ARDS? What are your initial ventilator management strategies? ARDS is not a primary diagnosis, so it is important to treat the underlying cause (pancreatitis, pneumonia, etc). Minimize further insults to the lungs. Optimize ventilator strategies- low tidal volume, target PEEP/FiO2 combination to target SpO2 88-95% Diagnosis and Management of ARDS Etiologies of ARDS Pneumonia, pulmonary contusions, aspiration, inhalation Trauma, burn Pancreatitis Transfusion-related acute lung injury (TRALI) ARDS diagnostic criteria: The Berlin Definition [1] Onset of respiratory failure within 1 week of an insult that is known to cause ARDS Bilateral fluffy infiltrates on CXR not explained by effusions/ infiltrates/ contusions/ lung collapse Respiratory failure not related to heart failure or fluid overload Oxygenation PaO2/FiO2 ratio with PEEP ≥5 cm H2O. Mild 200-300, moderate 100-200, severe ≤100. Basic principles of ARDS management [2,3] Low tidal volume ventilation- 4-8 mL/kg predicted body weight. Prevent volutrauma. Permissive hypercapnia- low TV ventilation leads to decreased minute ventilation, which leads to CO2 retention (hypercapnia). Hypercapnia is tolerated as long as pH remains above 7.2. Positive end-expiratory pressure (PEEP)- goal is avoiding overdistension and optimizing recruitment If ↑PEEP→ ↓plateau pressure: recruitmentIf ↑PEEP→ ↑plateau pressure: overdistension Optimizing mean airway pressure (MAP). Prolonged inspiratory:expiratory ratio Target plateau pressure <30, driving pressure ≤15. Recruitment manuevers Advanced strategies for persistent hypoxemia Prone positioning Airway Pressure Release Ventilation (APRV) Neuromuscular blockade Inhaled vasodilators Prostacyclin and nitric oxide ECMO High frequency oscillatory ventilation Open lung ventilation Dexamethasone Extracorporeal carbon dioxide removal (ECCO2R) References Ferguson ND et al. The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material. Intensive Care Med. 2012;38(10):1573-1582. Narendra DK et al. Update in Management of Severe Hypoxemic Respiratory Failure. Chest. 2017 Oct;152(4):867-879. SCCM Clinical Practice Guideline. Fan E et al. ATS/ SCCM CPG: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2017;195(9):1253-1263. Basic Principles of Ventilatory Management of ARDS Previous Next

< 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

2 Range Why Generalists Triumph in a Specialized World - Early expertise and overspecialization do not equate to success. Having a breadth of knowledge is key to solving issues that cross different disciplines. - An extensive explanation of the benefit of the breadth of knowledge and the risks of super sub-specialization. Loss of cross-communication between silos of isolated components. - Wicked problems- issues that require outside-the-box thinking, can't be solved by relying on specialization but needs interaction between various contexts. - Capitalize on the varied backgrounds when trying to solve a problem. Gathering 10 specialists who all share the same knowledge and experience to focus on one issue can easily lead to a dead-end- without the benefit of new and fresh ideas, the team ends up in a loop. Diversity can exponentially increase problem-solving by drawing from different perspectives, viewpoints, and thought processes. - Contrasts to the 10,000-hour rule, which asserts the benefits of focused training and specialization. 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 Pulmonary Embolism...pending Diagnosis and Treatment of Pulmonary Embolism Previous Next