< Back Abdominal Pain- Mesenteric Ischemia A 65-year-old male with 1 week of progressive abdominal pain presented to a small hospital. His medical history is significant for a myelofibrosis with chronic portal vein thrombosis. He underwent CT scan and was urgently transferred to the surgical ICU at the nearby tertiary hospital. CT abdomen and pelvis (coronal) CT abdomen and pelvis (axial) The abdomen pelvis CT showed chronic portal vein thrombosis with cavernous transformation as well as distal SMV thrombosis with inflammatory changes of the distal small bowel. There is a moderate amount of intra-abdominal fluid, including around the spleen and liver as well as in the pelvis. There is thickening of the small bowel wall as well as stranding and edema in the mesentery. There was also evidence of a splenorenal shunt. Representative slice from CT, axial Representative slice from CT, axial- labels Representative slice from CT, axial Representative slice from CT, axial- labels Differential diagnosis? Splenic injury secondary to splenomegaly (minor trauma can lead to splenic injury in the setting of splenomegaly). Bowel ischemia. Hollow viscus perforation. On arrival to the ICU, his abdominal exam revealed diffuse rebound tenderness. He became disoriented during our interview. Concurrent with our evaluation, the images with reviewed with radiology who reported that the fluid was not consistent with hemoperitoneum from a splenic injury. Based on our concern for bowel ischemia, he was taken to the operating room for abdominal exploration. He was noted to have a significant length of ischemic and necrotic bowel. This was resected and his bowel was left in discontinuity. He was returned to the ICU with an open abdomen and plan for second look laparotomy within 24 hours. Evaluation and Management of Acute Mesenteric Ischemia Causes Arterial Embolism- from the left atria (atrial fibrillation), left ventricle (decreased function following cardiac ischemia) or heart valves. Arterial Thrombosis- progression of underlying atherosclerotic disease leading to critical stenosis at the takeoff of the celiac or SMA from the aorta. Venous Thrombosis- hypercoagulable states, acute inflammatory process around the SMV (pancreatitis), post-operative following splenectomy or bariatric surgery. Non-occlusive mesenteria ischemia (NOMI)- low-flow through the SMA with vasoconstriction. Often having underying illness or cardiac failure, which is exacerbated by vasoconstrictive medications and hypovolemia. Presentation Severe abdominal pain, "pain out of proportion to exam" (report severe pain but abdominal exam doesn't elicit tenderness). Arterial thrombosis may be acute on chronic, if there is underlying chronic mesenteric ischemia. Diagnosis Etiology can be suspected based on symptoms and medical/ surgical history. Sudden onset is suggestive of arterial embolism. Known hypercoagulable state is suggestive of venous thrombosis. Chronic abdominal symptoms including pain with eating (food fear) and weight loss are suggestive of arterial thrombosis. Imaging Plain films may be non-specific, but may show free air or portal venous gas later in the course. Angiography Arterial thrombosis- often seen right at the takeoff of the celiac or SMA from the aorta. Arterial embolism- typically an occlusion of the celiac or SMA at a branch (versus right at the takeoff). Treatment Volume resuscitation, antibiotics Anticoagulation Surgery consultation for assessment of bowel viability and treatment of vessel occlusion 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

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

< Back What happens in the trauma bay? A glimpse into the inner workings of a trauma activation The radio crackles and the paramedic's voice cuts through the din of the emergency department. “Doctor to the radio”. The clock already started and time isn’t on our side. “30s-year-old male, a gunshot wound to the right arm and left back. GCS 7. Highest heart rate 110, lowest blood pressure 80 systolic. 5 minutes out.” The management of trauma starts at the time of injury, with bystanders and dispatched first responders. Immediate interventions can be performed on the scene, which is followed by rapid transport to the hospital. En route, care continues to be delivered as needed (starting IV, giving fluids/ blood, maintain an open airway, etc). The hospital is contacted to prepare them for an incoming patient. Key details dictate the resources that are mobilized in response. There are no universal criteria for what constitutes each level of trauma activation, and different hospitals have unique designations for the highest activation (Trauma Red, Level 1, Code 1, etc). However, triage is designed to rapidly transport the patient to the most appropriate facility. An adult trauma code 1 is paged out to the trauma team. As the team arrives, the minutes before the patient arrives are spent relaying key patient details shared from the pre-hospital team. For a hypotensive patient or report of massive bleeding, massive transfusion is initiated. Chest trauma? Chest tubes, possibly open thoracotomy tray. Extremity wounds? Check that the tourniquets are ready. Team roles are assigned, and a plan is discussed. When the patient arrives, the pre-hospital team presents key data to the entire team. At one of the facilities I trained, there was a standardized presentation. It was organized, succinct, and appropriately relevant; the trauma team and the pre-hospital team both knew what information was to be shared. Pre-hospital team report Age (or approximate age), gender, mechanism, time of injury, significant event details (prolonged extrication, death on the scene, etc). Significant pre-hospital interventions and events (tourniquet time and location, intubation, change in mental status). Presence of IV access (size and location) and administration of pre-hospital fluids or medications. Highest heart rate, lowest blood pressure. Trauma Evaluation/ ATLS After the report, the patient is transferred to the bed and the primary and secondary surveys are performed. Primary survey- assess airway patency, adequacy of breathing (bilateral breath sounds, chest rise and fall), circulation (control active hemorrhage, assess pulses), disability (rapid neurologic assessment with GCS and pupil exam), and exposure (remove clothing to facilitate exam, make sure they get covered with blankets to minimize hypothermia). Concurrent with the primary survey, IV access is obtained, blood is drawn, and interventions are performed based on the findings of the survey. If there are no immediate life-threatening injuries on the primary survey, the secondary survey is performed, which is a comprehensive head to toe exam (see below), including log rolling the patient to examine their back. Common diagnostic testing includes commonly, patients undergo FAST (see vignette "Blast Injury "), chest x-ray, and pelvis x-ray. Based on hemodynamic stability and injuries, patients are then dispositioned to the operating room, radiology for further imaging, admitted to the ICU or floor for ongoing resuscitation, observation, consults, serial exams, etc. Secondary Survey Head/ ears/ nose/ throat- facial abrasions/ ecchymosis/ tenderness, periorbital edema/ ecchymosis, crepitus, open wounds, blood from nares/ ears. Tympanic membrane. Jaw occlusion. Neck- c-collar in place, obvious ecchymosis, abrasions, open wounds, tenderness. Chest- wounds, ecchymosis, tenderness, crepitus. Axilla- wounds. Abdomen- wounds, ecchymosis, tenderness Pelvis- stability, pain. Back- midline spinal tenderness/ step-off, ecchymosis, abrasions, wounds. Rectal- tone, blood on rectal exam. Extremities- sensation/ motor strength. Abrasions, wounds, gross deformities Vascular- carotid, femoral, DP/PT, radial pulses bilaterally. GU- perineal ecchymosis or wounds, blood at meatus. Previous Next

< Back Thoracoabdominal Wound A 32-year-old male is brought to the ER after sustaining a gunshot wound to the right thoraco-abdomen. He is hemodynamically stable. What are the initial steps of evaluation and management? Imaging? Secondary survey to rule out other wounds. FAST exam. CXR. What injuries must be considered with these wounds and imaging patterns? Chest (heart, lungs, etc.), abdomen (solid organs or hollow viscus), and diaphragm. He underwent exploratory laparotomy. He was found to have a right diaphragm defect, which was repaired primarily. There was a transhepatic GSW and hepatorrhaphy was performed with chromic suture. A blast injury to the anterior gastro-esophageal junction was buttressed with an anterior Dor fundoplication. Management of Thoracoabdominal Wounds The thoraco-abdomen is between the nipples and the costal margin. Organs in the chest and abdomen can be injured, and the diaphragm is also at risk. Liver Trauma Management depends on how it is diagnosed and the patient's hemodynamic stability and physical exam. Diagnosed pre-operatively on CT scan + no concern for the need for operative intervention for concurrent injury→ non-operative management if the patient is hemodynamically stable without peritonitis. Embolization should be considered in adults with active arterial extravasation on CT. Operative intervention is indicated for hemodynamic instability, ongoing transfusion requirement, and/ or change in the abdominal exam. Diagnosed intra-operatively→ management depends on the severity and presence of bleeding, presence of concomitant injuries. Hemorrhage control is the immediate concern. Manual pressure and packing (sandwich lap pads above and below) first. If this is ineffective, use the Pringle maneuver (hepatic inflow control)→ if bleeding stops, it was either hepatic artery or portal venous in origin. If bleeding continues, hepatic vein or IVC are likely injured. Minimal bleeding can be controlled with cautery, hemostatic agents, omental packing, or argon beam coagulation. Moderate bleeding from a laceration from often be controlled with suture hepatorrhaphy. More significant bleeding may require non-anatomic resection or vessel ligation. Topical hemostatic agents Absorbable hemostatics Oxidized regenerated cellulose- Surgicel, Surgicel Fibrillar (sheet), Surgicel NuKnit Polysaccharide- Arista Porcine collagen (gelatin matrix)- sponge, film, or powder. Brands- Gelfoam, Gelfilm, Surgifoam. Bovine collagen (microfibrillar)- sponge, sheet, powder. Brands- Avitene, Ultrafoam. Sealants with thrombin or fibrin Thrombin, reconstituted (Recothrom) Thrombin + collagen + chondroitin sulfate (Hemoblast) Thrombin + bovine gelatin (Floseal) Thrombin + porcine gelatin (Surgiflo) Thrombin + fibrinogen + aprotinin + plasminogen (Tisseel) Thrombin + fibrinogen + albumin (Evicel) QuikClot- kaolin HemCon- chitosan If there is a trans-hepatic wound, tamponade can be created by threading a red rubber catheter through a Penrose drain, placing this into the wound, and then filling the Penrose with saline. Stabina S, Kaminskis A, Pupelis G. Start of Polytrauma Management in University Hospital: First Experience with Liver Trauma. Acta Chirurgica Latviensis. 2014;14(1):20-25. 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

< 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 Vent Mgmt #3: Pressures Inspiratory Pressures Pressure Controlled Ventilation (PCV) End-inspiratory pressure= alveolar pressure. The pressure is essentially constant during PCV- high flow at the beginning to get to target pressure, then flow tapers until it ends (no airflow at end inspiration). Can't measure resistance because flow rate is dynamic. Volume Controlled Ventilation (VCV) Peak inspiratory pressure (PIP)- maximal pressure with inspiration. Sum of plateau pressure and pressure required to overcome airway resistance. Keep <40 cm H2O, SCCM recommends below 30 for ARDS. Abnormalities: elevated PIP indicates high resistance (secretions, bronchospasm, biting tube). Plateau pressure= alveolar pressure. Mean pressure during end-inspiratory pause, basically when there is no air movement. Not affected by resistance. Goal ≤30 cm H2O. Abnormalities: elevated plateau pressure indicates poor compliance. Driving pressure= plateau - PEEP. Goal ≤15 cm H2O (>15 is associated with ↑mortality). PEEP can either improve or worsen driving pressure. If the set PEEP promotes recruitment→ ↓driving pressure. If the set PEEP creates overdistension of the alveoli→ ↑driving pressure. End Expiratory Pressure Positive end expiratory pressure (PEEP)- lowest pressure that avoids alveolar collapse, which occurs when intrapleural pressure is higher than intra-alveolar pressure. This is indicated by the lower bend on the pressure/ volume curve, known as the lower inflection point. Mean Airway Pressure Mean airway pressure (MAP)- average pressure the lungs are exposed to during the breathing cycle. One of the two parameters that determine oxygenation. - How to increase MAP: ↑PEEP. If using IRV, ↑inspiratory time (Thigh) and ↑inspiratory pressure (Phigh). Parameters that Impact Airway Pressures Resistance- change in pressure relative to flow (PIP - plateau/ peak inspiratory flow). Relationship between PIP and plateau is directly related to airway resistance. ↑PIP and [PIP - plateau >5 cmH2O]= ↑resistance (bronchospasm, ETT obstruction/ kink). ↑PIP and ↑plateau [PIP - plateau <5 cmH2O]= ↓compliance (PTX, ARDS, pneumonia, edema, auto-PEEP). Compliance- change in volume per change in pressure. Normal- 50-100 mL/ cm H2O Previous Next

< Back Pneumothorax American Thoracic Society- Patient Education | INFORMATION SERIES What is a Spontaneous Pneumothorax? Tube Thoracostomy (Chest Tube) You have a pneumothorax. This happens when your lung collapses and there is air in your chest. This can be spontaneous but is also frequently secondary to trauma. Imagine your lung is a balloon. When there is a hole in the balloon (penetrating wound to the chest, rib fracture, etc), the balloon collapses. When you breath in, the air moves from your airway, into the balloon and then out into your chest, the space around your lung. A chest tube is placed to evacuate the air from your chest and allow your lung (the balloon) to reexpand. As long as the hole in the lung is small, removing the air is generally all that is required. This is because when the lung is stuck back up to the inside of your chest, air stops leaking into the space around your lung. Surgery is infrequently required for management of a pneumothorax. This occurs when the lung fails to reinflate despite placement of a chest tube. It can also be required if there is an “air leak”. An air leak is the result of the ongoing leakage of air from the lung into the chest. The air that moves into the chest continues to be evacuated into the chest tube, and this is seen as bubbles in one window of the chest tube drainage canister. Spontaneous pneumothorax is often due to apical blebs, which are small areas at the lung of your lung that have thinned out and can rupture, with a similar results as a traumatic hole in the balloon that is the lung. Previous Next

< Back Pack the Guts Previous Next

Your Words Matter...And OCD isn't an Adjective "That's So Gay" Your Words Matter...And OCD isn't an Adjective "A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder." - DSM V (Diagnostic and Statistical Manual of Mental Disorders) Psychiatric disorders are a constellation of traits that impact a person's interaction with their environment. A formal diagnosis is based on a constellation of symptoms as well as an assessment of how functional the person is in their daily life. These disorders are outside the control of the individual, and they are pervasive in a way that interferes with daily life. We all have traits that could fit with a psychiatric diagnosis, but that doesn’t permit us to use the diagnosis as an adjective. We've all heard someone call themselves ADD because they're occasionally distracted or forgetful. People might call themselves or someone else OCD if they like a neat tidy environment. Bipolar is frequently used to describe (or insult) emotional people. What's the problem with using ADD as an explanation for occasional absent-mindedness, or calling someone bipolar because they are moody? Equating the presence of a trait of a disorder with an actual diagnosis minimizes the real struggle that many people experience every day. This is similar to using the words “retard/ retarded ” or “gay” to mean something is stupid or weird. In 2009, the Spread the Word: Inclusion campaign was created to eliminate the use of the “R-word”. In 2010, Rosa’s Law relabeled “mental retardation” to “intellectual disability”. The words “imbecile”, “idiot” and “moron” have also been relabeled as profound, severe, or moderate intellectual disability. The Stonewall Education Guides: Tackling Homophobic Language , which was published nearly 10 years ago (no date identified, but the document quoted literature published in 2012 describing “the previous 5 years”). They listed “that’s so gay” and “you’re so gay” as the two most commonly used homophobic phrases. They report that these phrases “are most often used to mean that something is bad or rubbish, with no conscious link to sexual orientation at all…a pupil might say ‘those trainers are so gay’ (to mean rubbish or uncool) or ‘stop being so gay’ (to mean stop being so annoying). Check out these PSAs discouraging people from using the phrase “that’s so gay”. "That's So Gay" Commercials Win Top Ad Council Award (starts at 1:16) Wanda Sykes Talks to Boys in a Diner Just like gay and retarded have been used out of their appropriate context to mean something is bad or stupid, here are some of the common traits that people mislabel as a "disorder" - OCD: excessive cleanliness, being overly tidy, “Type A” personality - ADHD: a tendency to make careless mistakes, forgetfulness, short attention span, easily distractable, tendency to interrupt conversations. - Depression: sadness, pessimistic, being an introvert - PTSD: bad memories associated with something trivial (the sound of a pager going off), bad dreams, fear of a particular event - Insomnia: occasional trouble initiating or maintaining sleep - Bipolar: moodiness, decreased need for sleep. - Anxiety: normal levels of anxious feelings It might not seem like a big deal- but try to imagine if you had a disorder that made normal interaction with your environment a struggle? Now imagine someone who can function normally but has a couple of “quirks” were to equate their experience with yours? You might feel that they are minimizing your disorder, invalidating your struggles- this might leave you feeling misunderstood and alone. Please think before you speak. Your words matter. Previous Next

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