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 Shot in the Chest- Aortic Occlusion A 30-year-old male sustained a gunshot wound to his left lower chest/ upper abdomen. On arrival, his heart rate was in the 50s with weakly palpable carotid and femoral pulses. Significantly hypotensive. Penetrating wound to the left lower chest wall with an occlusive dressing in place without ongoing hemorrhage. Initial workup and management? Assess mental status. Secure large-bore peripheral IV access and start massive transfusion. A rapid ultrasound of the chest and abdomen revealed fluid in the left chest, right upper quadrant, and no pericardial fluid. We placed a left chest tube with minimal output. Still hypotensive…treatment options? Resuscitative thoracotomy. Urgent OR if vitals improve with resuscitation. REBOA. A rapid secondary survey revealed a previous midline laparotomy. This would likely impede rapid access for aortic control during laparotomy, so REBOA was placed through a right femoral artery cutdown. With inflation of the REBOA, he had a return of cerebral perfusion with spontaneous movement of his extremities. He was transported emergently to the OR. We encountered massive hemoperitoneum and extensive dense intra-abdominal adhesions that prohibited easy access for a supra-celiac aortic clamp. There was ongoing hemorrhage despite REBOA. Other options to control intra-abdominal bleeding? Procedures directed at source (compression of the liver, splenectomy, etc). Aortic occlusion above the injury- stops all perfusion below the level of occlusion. This can be done from the chest through a left anterolateral thoracotomy or below the diaphragm (supra-celiac clamp). The patient underwent left thoracotomy for aortic cross-clamp. There were no obvious intra-thoracic injuries. Intra-abdominal injuries included a large Zone 1 retroperitoneal hematoma and left diaphragm injury, injuries to solid organs (liver and pancreas) and hollow viscus (stomach, small bowel, and colon). Management of massive sub-diaphragmatic hemorrhage Aortic occlusion decreases distal bleeding and redistributes blood volume to the myocardium and brain. This leads to a reduction in sub-diaphragmatic blood loss. Traditionally, this is accomplished through an open approach, either via thoracotomy or laparotomy. Concurrent with the expanding use of and comfort with endovascular approaches, endovascular occlusion of the aorta (REBOA) has been re-introduced as a less invasive approach. General indications Traumatic life-threatening hemorrhage below the diaphragm (non-compressible torso trauma) in patients in unresponsive shock Zone 1 (distal thoracic aorta)- control of severe intra-abdominal/ retroperitoneal hemorrhage, or for traumatic arrest. Zone 3 (above aortic bifurcation)- severe pelvic, junctional, or proximal lower extremity hemorrhage. Mixed results regarding clinical outcomes. Essentially the same time to aortic occlusion as resuscitative thoracotomy. Not shown to be significantly quicker at obtaining aortic occlusion than resuscitative thoracotomy. Brenner M et al. Joint statement from the American College of Surgeons Committee on Trauma (ACS COT) and the American College of Emergency Physicians (ACEP) regarding the clinical use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). Trauma Surg Acute Care Open. 2018;3(1):1-3. Previous Next

< Back Career Management 1. Create and maintain a curriculum vitae (Microsoft Word template below) that will serve as a comprehensive record of your professional and personal accomplishments. Keep this document up to date by adding new entries as they occur. Include details of your awards, training, leadership positions, committee participation, speaking engagements, and volunteer experiences. Also, list your non-professional talents, such as athletics, foreign language proficiency, and musical abilities. This will help you keep track of your achievements and provide a ready source of information when you need to update your CV. It is recommended to have a master document that includes everything, and you can tailor it to each submission. 2. Develop a personal database to store important documents, such as school transcripts, exam results, awards, training certificates, etc. Organize them in a manner that is easy to access when needed. For hard copies, use a 3-ring binder with clear sheet protectors. For digital copies, create designated folders on your computer. Name each file to in a way that your database is easy to organize and easy to search. This will help you avoid scrambling to locate essential documents when someone requests them. Do not rely on external databases to maintain your documents. Instead, download copies of important records. Create digital copies of important email conversations (scheduling rotations, arranging research projects, agreements, etc). 3. Keep templates of commonly created forms, such as requests for letters of recommendation or sponsorship , personal statements, etc. This will save you time and effort by allowing you to work from a prior document instead of starting from scratch each time. Request LOR Template .docx Download DOCX • 42KB Request Sponsorship Template .docx Download DOCX • 42KB 4. Establish and maintain relationships with trusted advisors who can review your written work, ranging from formal email messages to research papers. Choose someone with expertise in your field as well as someone who has strong spelling and grammar skills. Seek someone who will provide constructive feedback instead of blind positive support. By following these tips, you can build a strong foundation for your medical career and increase your chances of success. Remember, although mentors, friends, and family members can offer sound advice, ultimately, you are the best person to manage your medical training and career. Previous Next

Mac, Microsoft and PDFs < Back Technology #2 Mac, Microsoft and PDFs Mac Keyboard Shortcuts Close application= ⌘ + Q Switch between applications= ⌘ (press + hold)+ Tab (press + release) Screenshot (whole screen/ part of screen)= Shift + ⌘ + 3/ Shift + ⌘ + 4 Record your computer screen= Shift + ⌘ + 5 Page up/down= FN + up arrow/ down arrow Jump to top/bottom of document= FN + Command + left arrow/ right arrow Undo/ redo= Control + Z/ Control-Y Select all= ⌘ + A Copy/ paste highlighted text= ⌘ + C/ ⌘ + V Finder New Finder Window= ⌘ + N Close All Open Finder Windows= ⌘ + ⌥ + W Safari Autofill Webpage= Shift + ⌘ + A Switch between tabs= ⌘ + 1 (2, 3, etc) Microsoft Word Bold/ italicize/ underline highlighted text= ⌘ + B/ ⌘ + I/ ⌘ + U Add hyperlink= ⌘ + K Expand all hyperlinks (Word)= Fn + Opt + F9 Insert footnote/ endnote= ⌘ + ⌥ + F/ ⌘ + ⌥ + E Microsoft Excel Select all cells= ⌘ + A Select row= Shift + Space Select column= Ctrl + Space Hide rows/ columns= ⌘ + 0 / ⌘ + 9 Edit text in active cell= Ctrl + U New line of text in active cell= ⌥ + Return Format currency/ percentage= Ctrl + Shift + $/ Ctrl + Shift + % Insert current time= ⌘ + ; Insert current date= Ctrl + ; Links for How-Tos Mac keyboard shortcuts Create keyboard shortcuts for apps on Mac Microsoft Tips and Tricks Microsoft Word Keyboard Shortcuts Make different lines View all Abbreviations in a document Create and format a customized list style Save the current list style as a template to use in other documents Changing Level in a List Create embedded bookmarks and hyperlinks Format an image to be integrated with text versus between sections Change Text Formatting Microsoft Excel Keyboard Shortcuts Count cells- empty, data, specific data Combine text from multiple cells Highlight cells with specific data Creating a customized drop-down list Create a dependent customized drop-down list Microsoft PowerPoint Add Text to the slide background of a PowerPoint presentation Center an image Portable Document Format (PDF) [Mac Only] Combining PDF Documents Combining PDFs in a specific Order Modifying PDF Documents Microsoft Tips and Tricks .pdf Download PDF • 2.77MB Previous Next

< Back Pruritis Ani What is Pruritis Ani? Patient information: Pruritis Ani [American College of Colon and Rectal Surgeons] Pruritis ani is an unpleasant itching of the perianal skin (around the anus). Scratching can lead to further irritation and sets up a vicious cycle. Caused by other anorectal diseases, primary dermatology conditions, hygiene issues (sweat, stool, mucus on the skin), foods, soaps, clothing, or over-vigorous hygiene (aggressive wiping with rough material, use of topical cleaning agents). Diagnosis- detailed history, thorough exam to rule out underlying anorectal pathology What is conservative management for pruritis ani? Try not to scratch/ wipe/ scrub. It will just itch more, and things will get worse. Clean the anal area after bowel movements with hypoallergenic personal wipes. Do NOT over clean, as this may worsen your condition. Dry with a hairdryer on the cool setting instead of wiping the area dry. Use unscented Dove soap or dilute white vinegar for cleansing. AVOID potential contributing factors Citrus foods, caffeine-containing foods/ beverages- coffee, tea, cola, chocolate. Scented soaps, lotions, creams, powders, medicated wipes, witch hazel. Keep the area dry (can use cotton ball or a gauze pad). Avoid tight synthetic clothing that doesn’t breathe. Wear cotton undergarments. Maintain regular bowel movement with normal consistency (minimize stool leakage). Increase stool bulk by increasing fiber intake. Maintain adequate hydration- you MUST drink at least 64 ounces of fluid per day, in addition to increasing fiber intake. Medication Capsaicin- causes a low-grade burning sensation and decreases the perception of itching Zinc oxide- Apply a small amount of a barrier cream to the perianal skin in a thin layer. This will protect the skin from irritants. Mix Benadryl cream with the zinc oxide cream and apply it to the affected area. Benadryl- 25 mg by mouth at night for itching Patient Info- Pruritis Ani .pdf Download PDF • 58KB Patient Info- Fiber Guide .pdf Download PDF • 68KB Previous Next

< Back C dificle Colitis...pending Management of Clostridium Difficle Colitis 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

What language are we speaking? Speaking Greek < Back What language are we speaking? Medicine has a language all its own. Sometimes we use formal words for common terms, like sputum or phlegm to refer to snot. But a lot of words are unique to the medical field. When speaking with patients and families, the most important thing is communicating effectively. Using a slew of foreign and formal words might sound impressive, but everyone will likely be more confused when you leave the room. After years of education and training, words and phrases in the medical dictionary become second nature. Our conversations with colleagues, consultants, and peers are frequently saturated with this unique lexicon. Sometimes this even spills into your conversations outside of work, and your family and friends might start to pick up some of your common work terms. Patients and their families are not fluent in the language of healthcare unless they are employed in healthcare or have experienced frequent interactions with the healthcare field, such as being a caregiver for an ill family member or suffering from a chronic illness. Once you learn something, it’s difficult to remember a time when you didn’t know. If you’ve worked in healthcare, it’s obvious that laparoscopic cholecystectomy means using tiny incisions and long instruments to remove the gallbladder through the belly button. But unless you’ve had one yourself or know someone who has had one, these words might have little meaning. This language barrier can be even more challenging in the stressful environment encountered in the ICU. Several factors create additional barriers to effective communication. 1. Patients in the ICU are sicker and the threat of death or serious disability is more apparent. This can create emotional distress that occupies or distracts families as they try to ask questions and get answers, impairing their ability to thoroughly understand, even if the healthcare team provides very detailed, comprehensive information. 2. When individuals receive bad news, they process/ remember very little after the initial shocking revelation. 3. The higher acuity and sometimes the need for urgent intervention can add time constraints. This creates an additional barrier to effective communication- having to convey the information and potentially obtain consent for treatment and procedures while balancing the ever-present demands of multiple urgent procedures and critical patients to attend to. Families can get information from different members of the healthcare team. Sometimes the nature of the conversation demands the skills of the most experienced provider. However, young trainees sometimes converse with families as well. It’s easy to forget the process of learning how to effectively communicate with families in difficult situations. Listening to phone conversations between team members and family can be enlightening. As young trainees are becoming much more facile with the unique language of the ICU, it can start to infiltrate these discussions. For example, imagine you are caring for a patient who was just admitted to the ICU with a severe traumatic brain injury. When you’re reporting to the accepting team, you’ll use words like subdural hematoma, midline shift, cerebral edema, and severe TBI. When discussing the patient's current clinical status, you might mention that they are over-breathing the ventilator or that they don’t have brainstem reflexes. When developing a management plan, you might discuss the utility of ICP monitoring and debate the use of a bolt or an EVD, the benefits of hypertonic saline versus mannitol for hyperosmolar therapy, whether or not to hyperventilate the patient and the potential for a craniectomy. While these will be readily understood by your colleagues, these are likely foreign terms for most family members. So here are some tips for talking to family and friends, especially during initial conversations. 1. Avoid unfamiliar medical terminology (for example: severe TBI, hypertonic saline). Instead, opt for descriptors such as “bad head injury” or “medication to protect the brain”. 2. Avoid unnecessary details. Don’t ramble on about everything that has happened, especially while they are waiting to hear if their loved one is alive or dead. After you’ve told them their family member is alive, they aren’t likely to hear much else. 3. Avoid revealing that a patient has died over the phone, especially in your initial discussion with the family. 4. Avoid acronyms (for example: TBI, GCS) 5. DO give them a chance to ask questions. 6. DO encourage them to write down their questions as they think of them and reassure them that they can ask questions throughout the process. Previous Next

Ratios < Back Kitchen Hacks #5 Ratios Cooking with Ratios Bread 5:3 flour to water- for example, 300g flour and 180g water. With this ratio in your arsenal, the world of bread is at your fingertips. You can explore different flours, hydrations, and additions like seeds and nuts from here. Salt: Around 2% of the flour weight (e.g. 6g salt for 300g flour) Yeast: Around 1% of the flour weight (e.g. 3g yeast for 300g flour) Muffin/Quick Breads 2:2:1:1 flour:liquid:eggs:fat Baker Move: Baking times and temps can vary based on something as simple as the humidity in the air. Pros test the doneness of muffins, quick breads and cakes by simply inserting a toothpick. If it comes out clean, they are ready to cool. Biscuit 3:2:1 flour:liquid:fat Baker Move: Pros always scoop flour, sugar or other dry ingredient into a measuring cup, then use the back of a knife or other straight edge to level it off. Vinaigrette 3:1 oil to vinegar. Add herbs, garlic, or mustard to elevate your dressing Cookies 3:2:1 flour:butter:sugar Other ingredients like eggs, baking powder, and flavourings can be added, but the core 3:2:1 ratio for the main dry, fat, and sweet components is the foundation. Baker Move: Using a dough scoop (like a small ice cream scoop) to portion equal-size cookies adds a professional touch to your finished cookie plate. Pound Cake 1:1:1:1 flour: egg: fat (unsalted butter): sugar Baker Move: Pull your butter and eggs out of the fridge a couple of hours before you're ready to bake. Room-temperature butter is better for creaming, and you'll want the eggs at the same temperature to prevent them from seizing. Pancakes 2 parts flour: 2 parts liquid: 1 part eggs: 1/2-part fat Baker Move: Slowly incorporate the liquid into the dry ingredients while whisking constantly for effortless, lump-free pancake batter. Meringue 2 parts sugar: 1 part egg whites or 1 part sugar: 1 part egg yolks Baker Move: Avoid cracks in your perfectly piped meringues by keeping your oven door closed while they dry out. Yep, that means no peeking. Pie Dough 3:2:1 flour:butter:water Baker Move: Soggy-bottomed pie crusts, be gone! Pros know to par-bake their crusts for fresh fillings. Fritter 2:2:1 flour:liquid:egg Baker Move: The key to a crispy fritter is to never crowd the pan. Drop too many in the frying oil at once and the temperature will plummet, producing a greasy, mushy fritter. Custard 2:1 eggs:liquid Baker Move: Once you have that ratio down, remember to strain your cooked custard through a fine mesh sieve to remove any lumps. Crepes 1/2:1:1 flour:liquid:egg Baker Move: Crepe batter needs time to set up, preferably overnight in the fridge. Links Cooking with Ratios Food Network Previous Next

3 Everybody Lies Big Data, New Data, and What the Internet Can Tell Us About Who We Really Are - The staggering amount of data available and the power to make predictions. - Internet search bars have entered society as a secret place to ask our most urgent/ personal/ embarrassing questions without risk of guilt or shame from others discovering intimate details about us. People lie on job interviews, online surveys, and almost anywhere they are at risk of being revealed, which introduces a significant bias in database queries. In contrast, there is no motivation to lie to the anonymous search bar. - Evaluating internet searches can reveal an infinite amount of information about society as a whole. Monitoring internet searches during presidential addresses, evaluating searches for unemployment offices, what to say on first dates- there is so much data that can be harnessed to understand society. Previous Next

< Back Before Surgery American College of Surgeons (ACS) Operation Brochures for Patients Patient Education: Preparing for Your Surgery How Can I Be Strong for Surgery? Strong for Surgery is a program that works with surgeons and hospitals to provide tools like checklists that surgeons can use to assess your risks in four target areas: nutrition, blood sugar control, smoking cessation, and medications. You can lower your risk by being better prepared for your operation. NSQIP Surgical Risk Calculator Disclaimer: The ACS NSQIP Surgical Risk Calculator estimates the chance of an unfavorable outcome (such as a complication or death) after surgery. The risk is estimated based upon information the patient gives to the healthcare provider about prior health history. The estimates are calculated using data from a large number of patients who had a surgical procedure similar to the one the patient may have. Previous Next

< Back AKI...pending Management of Acute Kidney Injury Previous Next