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< 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

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How to play nice in the sand box...and why it matters Consults < Back How to play nice in the sand box...and why it matters The department of Acute Care Surgery and Emergency Medicine frequently interact to discuss consults. Unfortunately, several factors predispose to an adversarial relationship between the ER provider and the consultant.(1) I won't pretend that I didn't contribute to some of the negative interactions I've had while responding to consults. However, I'm grateful that my years of experience have provided me with insight and perspective that reframed my thoughts about the consultation process. What are the different types of consults? #1 The patient requires something that is beyond the scope of practice of the emergency provider. This includes everything from hospital admission, surgical or procedural intervention (appendectomy, stop the bleeding from a penetrating neck wound, cardiac catheterization), or a plan for close follow-up. How to Respond? This is why we chose our specialty, and our business is patient care. If a consultant is not responsive, it might be because they are caring for more urgent clinical issues. It's also possible that they are a generally unpleasant person, and it has no relation to the nature of the consult..some people can be difficult regardless of the scenario. Admittedly, it might also be 2 am, and they just fell back asleep after their last page. As much as I hate to admit, it's harder to be pleasant on the phone when you're absolutely exhausted. #2 The unclear diagnosis. The patient is presenting with a complex issue, or the diagnosis may be outside the provider's experience. This could be the first time they encounter a particular clinical scenario or an unusual presentation of a common diagnosis. How to Respond? Depends on the scenario. If that patient requires emergent assistance, prioritize their needs. If no emergent need, but further workup is needed, provide whatever recommendations you can regarding the next steps of the diagnostic workup. If the patient's case falls under your specialty, refer back to #1. #3 The emergency room provider doesn't know who the appropriate consultant is, or they have had no luck reaching them. How to Respond? It's easy to brush off a call when the primary provider called the wrong service. This might occur if the provider cannot reach a particular specialist, and you are the next best option (example- plastic surgeon doesn't respond for a consult on a patient with a wound complication). Please, if you know how to reach that provider, lend a hand. Or, if they call the wrong service, take the time to give a little guidance about whom they should have called. They aren't trying to waste your time- they are likely also busy, and calling multiple consultants is not the best way to spend their time either. Whatever assistance you can provide is best for the patient. #4 The controversial consult. In my experience, during years of working with surgeons and emergency physicians, probably one of the most contentious consultations is the consultation for something that the consultant considers inappropriately simple or unnecessary. The surgeon may think that the issue is trivial or the need is non-existent and feel that the provider should be capable of resolving the issue without calling a surgeon. This disconnect might be the key patient interaction that can set the tone for the relationship between departments. How to Respond? First, and most importantly, please don't be dismissive when someone calls you for a consult. If you are receiving a call, it's because the person on the other end of the phone (and therefore the patient they are caring for) needs your help. Surgeons, along with other specialists, have extensive specific expertise, so it's easy to lose perspective and presume that the knowledge in our head is universal. It's become almost intuitive in our minds, so we might forget that the primary provider does NOT have the same specialization. We each chose our respective specialties, and our training and biases are quite divergent. It is unreasonable to expect ER physicians to share the same depth of knowledge in each of the many specialties, just as each of the specialists would not have the same ability to deftly juggle the wide array of clinical scenarios managed in the ER. I remember the plastic surgeon who showed me how to do a scar revision on a young woman's face. He spent his career training and practicing to perform plastic surgery. It was simple in his hands, but that doesn't mean the woman would have a similar outcome if the needle driver was in my hand. Please, think of the patient's best interest. Yes, the primary provider may be "an idiot" or "lazy" or whatever. But consider the other possibilities. I prefer to give my colleagues the benefit of the doubt and avoid automatically assuming incompetence. Regardless of the underlying issue, whether it's a flaw of the provider or its truly beyond their capability, the patient needs someone to take care of them. Do the right thing for the patient- in the end, that's what matters. 1. Koo A, Bothwell J. Tips for Working with Consultants. ACEP Now. Nov 2017. Previous Next

Favorite Websites and Apps < Back Kitchen Hacks #4 Favorite Websites and Apps How Sweet Eats Eating Well (previously Cooking Light) Cooking Substitutions Previous Next

< Back GERD What is GERD? Gastroesophageal Reflux Disease (GERD), more commonly known as heartburn, is caused by acid from the stomach moving into the esophagus, which causes a burning pain in the middle of the chest. Anatomy After swallowing, food moves down the esophagus and into the stomach. The lower esophageal sphincter (LES), which is at the connection between the esophagus and stomach, prevents stomach contents from moving back into the esophagus. The lower esophageal sphincter is located below the diaphragm, where pressure from the abdominal organs helps keep the sphincter closed. There are different causes of GERD, but the lower esophageal sphincter is key to preventing reflux. See below for more details about why GERD occurs. Source: UpToDate Images: Gastroesophageal Reflux (GERD) Causes of GERD Decreased pressure of the lower esophageal sphincter- if the lower esophageal sphincter is too loose/ relaxed, stomach contents move more easily into the esophagus. This can be a pre-existing condition but it can also be caused or worsened by lifestyle habits. For example, tobacco and certain foods such as alcohol, chocolate, caffeine, carbonation, mint, citrus/ tomato-based foods, spicy/ fried/ fatty foods, can also decrease the pressure of the sphincter. Eating too much/ too fast→ overfilling the stomach leads to increased pressure, causing stomach contents to be pushed into the esophagus Laying flat- when you are standing or sitting upright gravity helps avoid reflux by keeping food in the stomach, but when laying flat, stomach contents can move into the esophagus more easily. This is why symptoms are often more severe at night or first thing in the morning. Hiatal hernia - when the lower esophageal sphincter is able to move into the chest, it no longer has the external pressure normally present when it’s in it’s correct position, and it more easily allows stomach contents to move into the esophagus. See link for image. Obesity or pregnancy- increased pressure on the abdomen from excess weight can put pressure on the stomach and allows stomach contents to move into the esophagus for easily. GERD: Symptoms and Causes [Mayo Clinic: Patient Care & Health Information] Diagnosis Symptoms are often adequate to diagnosis GERD. A swallow study can provide further information. This study is performed in radiology, and involves drinking contrast material and having x-ray images taken to evaluate the esophagus and stomach while you swallow. This study can diagnose esophageal problems, such as poor muscle function leading to swallowing difficulty. In addition, a hiatal hernia can be identified. John Hopkins Medicine: Barium Swallow An esophagogastroduodenoscopy (EGD), also known as an upper endoscopy (see link) can be used to assess the inner lining of the esophagus, stomach and the first part of the small intestine (duodenum). There are many things that can be identified on an EGD, but specifically related to GERD, damage to the lining of the esophagus and the presence of a hiatal hernia can be identified with an EGD. Patient education: Upper endoscopy (Beyond the Basics) [UpToDate] Upper Endoscopy [Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)] Additional testing can be performed based on symptoms, results of initial testing and response to treatment. Esophageal manometry- a study to evaluate the muscle function of the esophagus ( pH test- a study to evaluate how much acid the esophagus is exposed to, which is one measure of the severity of GERD. GERD: Diagnosis and Treatment [Mayo Clinic: Patient Care & Health Information] Treatment Lifestyle Modifications [ Patient Handout: Anti-Reflux Diet and Lifestyle Modifications ] Eat slowly, avoid eating large meals and stop eating before you feel full. Avoiding alcohol, chocolate, caffeine, carbonation, mint, citrus/ tomato-based foods, spicy/ fried/ fatty foods. Avoid lying down for at least 2-3 hours after meals. Don't snack after dinner/ before bed. Elevating the head of the bed by 6-8 inches. This is NOT done by placing multiple pillows under your head- multiple pillows would actually increase pressure in the abdomen (like doing a sit-up or crunch). For more information, see this guide from the Kingsley clinic. Lose weight. Stop smoking. Avoid tight-fitting clothing. Medication Over the counter antacids Prescription medication Surgery Depending on how well medication and lifestyle modifications improve your GERD symptoms, and depending on the results of your other studies, such as your swallow study, esophageal manometry and pH testing, surgery may be an option for GERD. UpToDate Patient Education Patient Education: Gastroesophageal reflux disease in adults (Beyond the Basics) Previous Next

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

12 Barking Up The Wrong Tree The Surprising Science Behind Why Everything You Know About Success Is (Mostly) Wrong - Good grades in school- likely to be a "rule follower", and less likely to be innovative, think outside the box. - Introverts are more likely to be experts, extroverts tend to make more money (socializing, "networking"). We should look at "networking" as "making friends". This disputes the "nice guys finish last"... - Match your strengths/ passion/ skill to the right context. - Flattery (sucking up to the boss) can work in the short term, but in the end, when people see their colleagues/ neighbors/ etc cutting corners and reaping benefits, this leads to a general collapse into distrust and rule-breaking. - IQ only matters up to a certain point, but then it yields diminishing returns. After that, hard work is what makes the difference. - Tradeoffs- every hour that you spend working is an hour spent away from other things (family, hobbies). In this age of constant accessibility, you have to decide to leave work behind (ignore your emails when you're at your kid's ball game). - Gratitude in relationships- on their deathbed, people regret working too much and not saying thanks to the people in their life. - Some helpful things I learned...please note that tact and delivery matter and these are not appropriate in every scenario. - When someone is getting upset or frustrated and starts yelling, "Please speak more slowly, I want to help." Or try, "What would you like me to do?" - When someone is upset, validate/ name their feeling. "Sounds like you’re angry/ hurt/ frustrated." If you're wrong, give them the chance to correct you. - Gratitude to relationships. Previous Next

How not to lose everything < Back Organizational Hacks How not to lose everything All my life, I've been forgetful and easily distractible. I joke that I'd lose my head if it wasn't attached. This challenge is part of my ADHD, and I can't overcome it with sheer willpower. The list of things that I've lost over the years is staggering- homework (oh so much homework…it was usually stuffed somewhere in my locker), clothing, books, charging cables, water bottles, earrings (what am I supposed to do with the remaining single earrings?) and a white polar bear stuffed animal (he was left in a hotel room on a road trip as a child). I'm looking forward to learning where all my things went when I die and go to heaven. So if this can’t be overcome with sheer willpower, how can you adapt? Check out these techniques or tools to see if you find something that would be useful for yourself. Information * Create a tool for yourself for storing the data you need to be able to access reliably. This website is full of high-yield medical information that is rapidly accessible, but a website is a labor-intensive option. You don’t have to invest time and money into a website. Here are some other options (check out this post for more details ): - Invest in a planner . Electronic options that sync are useful because they minimize the need to re-write things in multiple places. Another option that I prefer is one notebook that keeps all my events in one place, along with my collection of lists and reminders. - Write everything down. My planner is my note repository. The Apple Notes application is also useful because it can sync across multiple Apple devices. At home or work, dry-erase poster paper can be used to take notes, keep track of schedules and provide reminders for long-term tasks and due dates. - Trello is a user-friendly free application with multiple functions, including the creation of lists, storage of documents, and the ability to share notes or documents among team members/ family members. Items * Magnet strips . Using magnetic sheets the size of business cards, cut pieces and strips to put on various items and stick them to the fridge or other magnetic surface of your choice. For example, if you use dry-erase poster paper on the refrigerator, thin strips of magnet can be cut to fit along the length of several dry eraser markers, so they're always on hand when you have something to jot on the whiteboard * Keys on a hook by the front door. 3M hooks work well, but the hook design isn’t as important as placement, ideally not in direct sight of the door. You can also hang your work ID badge or any other small items you need when you leave the house. * Keep track of all your cords with these tie wraps . Inexpensive and sturdy. I didn’t think there was any way I’d use 50- I figured maybe a couple, just for a handful of my charging cables that always end up in a jumble. But trust me, you'll find plenty of uses for them! Finances and Important Documents * Save receipts for anything valuable. If it was purchased online, download the digital receipt. Use the "Create PDF" function to combine receipts. For paper receipts, an envelope in a drawer is a simple option. Every so often, review the receipts, and if there is anything you don't need anymore, toss it. * Paper shredder . Anything with personal information should be destroyed before being thrown away. This is technically not about avoiding losing something, but it’s an important task so it is included here. * Taxes. Instead of waiting until tax season, keep track of key documents and expenses throughout the year. A running spreadsheet of business expenses, donations, etc, can avoid the frantic search in March. * Metal rack of hanging file folders. Each folder has a different label, including taxes (donation receipts, investment statements, etc), moves (signed leases, welcome packet with key information, etc), and business (bank paperwork, original EIN and registration forms, deposited checks). 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

Medical Literature Evidence-Based Medicine After you have established a firm foundation of the basics of your chosen specialty, you're ready to develop regular habits to stay up to date on the newest research. Evidence-based medicine is the basis of high-quality patient care, but it can seem overwhelming to try to keep up with the ever-growing body of research. There are countless journals, and it would be time-consuming to search them regularly. So how does one go about navigating the vast ocean of available data? Registering for email alerts is a simple way to get notified when there are new publications. With a quick skim through the article titles to see if anything is relevant, followed by a review of the abstract/ article itself, you can be on the cutting edge of the latest information in your field. Several require individual registration, but it's a very simple and quick process. Many journals require a subscription, often available through your medical school or hospital library. If you are military, you have access to AMEDD Virtual Library (abundant medical resource collection). Thankfully, three publishers (LWW Wolters Kluwer , Springer and Elsevier ) have centralized their journals, so you can quickly subscribe to several journals [these journals are designated by L, S or E]. Medicine and Critical Care Journal of the Ameri can Medical Association New England Journal of Medicine Intensive Care Medicine Critical Care Medicine (L) Current Opinions in Critical Care (L) Journal of Intensive Care (S) Critical Care (S) Journal of Critical Care (E) Critical Care Clinics (E) Surgery World Journal of Surgery World Journal of GI Surgery JAMA Surgery J Gastrointestinal Surg Advances in Surgery Annals of Surgery (L) Annals of Surgery Open (L) BMC Surgery (S) Surgery (E) American Journal of Surgery (E) Journal of the American College of Surgeons (E) Surgical Clinics of North America (E) Advances in Surgery (E) Trauma and Emergency Surgery European J Trauma and Emergency Surgery Trauma Surgery and Acute Care Open Journal of Trauma and Acute Care Surgery (L) World Journal of Emergency Surgery (S) World Neurosurgery (E) Other Specialities Journal of Neurotrauma World Journal of Cardiology JAMA Cardiology JAMA Neurology JAMA Network Open Anesthesia and Analgesia (L) Current Opinion in Anesthesiology (L) Current Opinion in Clinical Nutrition (L) Current Opinion in Infectious Diseases (L) Current Opinion in Neurology (L) Diseases of the Colon and Rectum (L) Journal of the American College of Cardiology (E)

Surgery trainee education. Trauma surgeon. Acute Care Surgery. Collaboration Interested in being a guest contributor? Any suggestions and contributions will be promptly reviewed and added to the appropriate page/ subpage. The contributor will be noted on the website- you can choose if you want your name or Twitter handle or whatever other identification you would like (or none at all if you would like to be anonymous). Content currently under development. Note- this list is NOT all-inclusive. Database of clinical vignettes in key topics of trauma, critical care and emergency general surgery. Focused on more complex scenarios (ie not run-of-the-mill appendicitis)! Please check out the vignettes I currently have to get an idea of what I’m trying to create- and reach out with any suggestions or cases. Literature reviews - deep dives, high-yield articles, etc Procedural or skill tutorials (pre-peritoneal packing, using the ultrasound in critical care, reading a chest x-ray). Each tutorial is followed by a list of primary sources, encouraging readers to pull information from multiple references. If there is any particular procedure or skill that you would like to create a tutorial for, or something that is currently on the website that you would like to enhance (for example, more advanced ultrasound techniques or ventilator settings), please feel free to reach out with suggestions! There is a wide array of other content that you can add to as well. Note templates Recommendations on networking opportunities Recommendations on social media accounts to follow Educational resources (textbooks, journal articles, training courses, web based open access medical education) Please send me an email (form at the bottom of the page) or contact me on Twitter @doc_on_the_run if you have any questions or want to submit something.

Surgery trainee education. Trauma surgeon. Acute Care Surgery. FAQs Why did you make this website? Over these years of learning about the practice of surgery, I've also learned a lot about myself. I am not an expert, and I did not follow a typical pathway- but I have some knowledge and resources to share. As I transition into my new Acute Care Surgeon role after 17 years in training, I'm pausing to share my experience, tips for success, and random nuggets of wisdom. This will be a work in progress, and I look forward to seeing how it evolves. My goal is to share my experience and knowledge in the hopes of helping those who desire to follow this path. But why do we need another medical education website? There are so many good resources already... There are endless ways to explain clinical concepts- pictures, text, analogies, clinical cases, podcast discussions of cases or principles, review articles, etc. There are also different learning styles. When I was trying to grasp advanced ventilator management, I read basic critical care textbooks, a book dedicated solely to ventilator management, and various websites and journal articles. This website is another way to interact with the information. Hopefully you will understand some of the concepts in a new way that helps you remember and apply them in clinical scenarios. In addition, I have also tried to create a comprehensive collection of all the useful resources I know, like apps and open access medical education resources (websites, clinical guidelines, etc) in one place for trainees to What does Doc on the Run mean? The summer before my last year of medical school was the start of my running career. My focus was enjoying the outdoors, not pace or distance. During my residency, I met someone who helped me refine my running. I started timing myself, training, and racing. Within a year or two, I pushed through personal barriers to become a "runner." My first half marathon was on Thanksgiving in my third year of surgical residency. I am at the end of my formal training, I am now an Acute Care Surgeon. As a surgeon, there are numerous factors that I can't control. It's fast-paced, demanding, and dynamic. I enjoy the organized chaos and high-stakes cases. Running is key to my work-life balance. Unlike in the operating room or the trauma bay, I have control over most aspects of my runs- pace, distance, route, and thoughts. It's not chaotic- it's basically the polar opposite of my work. During the day, my mind is going a million miles an hour. When I run, everything becomes clearer- I can solve problems, mull over ideas, or process dilemmas. And perhaps the most concrete impact is the runner's high that I enjoy after finishing. I have continued to run 10Ks, 10 milers, and the occasional 5K or 15K. I have learned more about the science of running (HR training zones, different paces for tempo/ interval/ long runs/ short runs) and I've learned how to adapt training schedules to fit my life. Unfortunately, I have suffered my share of injuries, including most recently nerve impingement in my foot. While I may have scaled back, running will always be part of my identity. Did you really build this website yourself? Yes, I did. No, I didn't do all the intricate coding by myself. But I did design, format, and create the content. So are you a computer/ technology guru? Whatever I know about technology, I learned from my brother and from spending many hours researching problems online. While my parents might consider me an expert, I literally just search online to solve most issues. When I get to the end of the internet and still haven't found the solution, my next step is Apple tech support (obviously only if the problem is with my iPhone or Mac). What did you learn while making this website? - Formatting the working space on a website - URL redirect - Domains and subdomains - Search engine optimization (SEO) - Establishing custom domains - Which text/ background colors are easiest to read - Anchors If you weren't an Acute Care Surgeon, what would you do? I'd be a chef. I love cooking! Is there anything that is overwhelmingly gross in your job? I have had almost every body fluid on me- stool, urine, blood, etc. So very little grosses me out. But I can't stand oral or nasal secretions (aka saliva, slobber, snot, etc.).