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

10 < Back Research Resources Literature Search PubMed . National Library of Medicine, database to search for biomedical and life sciences literature. Cochrane Library . Leading journal and database for systematic reviews in health care. For a more extensive list of surgical and critical care references, please see Medical Literature . References Zotero . Free computer program that organizes all your medical literature. Highly recommend. You can create folders and add tags to help index your documents. If you want to sync your documents across devices (phone, tablet, etc), you can purchase a storage subscription. 2 GB costs $20/ year, 6 GB costs $60/ year and $120/ year gives you unlimited data storage. Tools and shortcuts in Zotero: Automatically add articles from any electronic resource (PubMed, journal website, etc). Easily tag and sort documents into categories to help easily locate articles on a particular topic. Search your entire database of documents for any author, title, year of publication, and journal source, and perhaps most usefully- search for any individual words to find a comprehensive list of documents that address a particular topic. There is a note panel on the right side of the document that allows you to type a note while reading the article. Automatically create a note from the text you highlight while reading an article. Alternatively, if you choose to type your own notes, you can also highlight text and add a single highlighted section to the note. EndNote . Free application that simplifies citation management. Use Cite While You Write to embed references while writing manuscripts. Data Analysis Covidence . Systematic review management program. It requires a subscription. GraphPad QuickCalcs . I do NOT endorse this as the most reliable/ valid/ precise options for doing statistics. HOWEVER, I have used it for simple calculations and it always matches or is incredibly close to what my formally trained statistician reported. PubMed . National Library of Medicine, database to search for biomedical and life sciences literature. Cochrane Library . Leading journal and database for systematic reviews in health care. Research Manuscript Submission Manuscript Title Page Template .docx Download DOCX • 49KB Manuscript Cover Letter Template .docx Download DOCX • 49KB Previous Next

< Back Delirium...what's going on? A 29-year-old male with moderate traumatic brain injury (TBI) remains intubated in the surgical ICU (SICU) due to agitation/ delirium during daily spontaneous awakening and breathing trials (SAT/ SBT). What are the clinical priorities? Rule out acute processes that can cause agitation and delirium, such as anemia, acidosis, hypoxemia, infection, intra-cranial process, fever, and an adverse drug reaction. Other potential causes? Immobility, "lines and tubes." Isolation, disorientation, lack of normal sleep-wake patterns Endocrine or metabolic derangements Organ dysfunction (renal disease, liver disease, etc) Withdrawal from chronic home medications (benzodiazepines, alcohol, psychiatric medication, etc.). What are the treatment principles for agitation and delirium? Treat organic reversible causes (treat infection, minimize unnecessary medication, etc.) Implement non-pharmacology therapy (sleep-wake cycles, lights and stimulation during the day and darkness at night) Pharmacologic agents can be used once reversible causes are remedied and non-pharmacologic therapy has been instituted. After the optimization of non-pharmacologic therapy, the patient was successfully extubated. A few days later on rounds, the patient was sitting up in bed. During our conversation, I noticed that he was drinking a Mountain Dew. His mom told us that he drinks multiple Mountain Dews every day (read- 6 or more). I told her that I suspect this had a significant role in his altered mental status during attempts at ventilator liberation. Management of Agitation and Delirium Definition Agitation is a psychomotor disturbance characterized by excessive motor activity and a feeling of “inner tension”. Delirium is an altered consciousness with reduced focus/ cognitive function. It is abrupt in onset and can have a fluctuating presentation. High prevelance, often misdiagnosed. Classified as hypoactive (most common, worse prognosis, difficult to diagnose), hyperactive (better prognosis) or mixed. Etiologies Acute illness- sepsis , electrolyte/ metabolism disorders, hyperthermia, hypoxia, hypotension, EtOH withdrawal, organ dysfunction, polytrauma, emergency surgery Patient factors- elderly, history of depression/ stroke/ dementia, history of EtOH abuse, tobacco use. Hearing or vision impairment. Iatrogenic- noise, discomfort, pain, sedative/ analgesics, ventilator dyssynchrony. Exacerbated by pain, anxiety, discomfort. Diagnosis [see charts below] Assess consciousness with Richmond Agitation-Sedation Scale (RASS). 10 point scale, ranging from combative to unarousable. Assess for delirium with Confusion Assessment Method for the ICU (CAM-ICU). 1-2 min test, 98% accurate in diagnosing delirium. Assess over 24 hrs to capture nocturnal symptoms. Non-Pharmacologic Treatment of Delirium Diagnose and manage underlying acute illness - Treat sepsis as appropriate- antibiotics, source control, etc. - Correct hypoxia, metabolic disturbances, dehydration, hyperthermia Non-pharmacologic interventions for anxiety/ discomfort[1] Periodic reorientation and reassurance from nursing staff Cognitive stimulation Correction of sensory deficits Management of environment (reassess need for invasive devices) Normalize sleep/wake cycles Minimize iatrogenic factors (sedation) Pharmacologic Therapy for Delirium Typical anti-psychotic- Haloperidol. MIND and HOPE-ICU trial- no difference in duration of delirium.[2,3] AID-ICU trial- no difference in mortality.[4] Atypical anti-psychotic- Quetiapine, Ziprasidone MIND-USA trial- no difference in delirium duration with either agent [5] Dexmedetomidine MENDS and SEDCOM trials- ↓ mechanical ventilation and ↓ delirium vs benzos [6,7] MIDEX and Prodex trial- non-inferior compared to benzos/ Propofol [8] DahLIA trial- quicker and more sustained resolution of delirium vs placebo [9] SPICE III Trial- similar mortality and similar number of delirium-free days [10] MENDS II Trial- similar number of delirium-free days vs Propofol.[11] Melatonin Pro-MEDIC Trial- prophylactic melatonin didn't decrease delirium prevalence[12] Assessment for Caffeine Withdrawal Obtaining a detailed patient history, or even a focused history of the most pertinent diagnoses or medication (blood thinners, cardiac disease) is often challenging in traumatically injured parents who may have decreased mental status due to injury or intoxication. Documenting daily caffeine intake is not typically a key component in a surgical history. However, caffeine is readily available and is the most commonly used drug in the world.[13] Unfortunately, it has significant systemic effects. Along with nicotine, it is gaining more attention as a potential etiology of altered mental status or other symptoms that would typically prompt extensive work-up. If a patient has persistent altered mental status after evaluating typical causes, consider the possibility that the patient could be missing their usual caffeine fix. "Withdrawal symptoms caused by people abruptly stopping smoking or drinking tea and coffee can include nausea, vomiting, headaches, and delirium and can last for up to two weeks."[14] References Faustino TN et al. Effectiveness of combined non-pharmacological interventions in the prevention of delirium in critically ill patients: A randomized clinical trial. J Crit Care. 2022;68:114-120. MIND Trial. Girard TD et al. Feasibility, efficacy, and safety of antipsychotics for intensive care unit delirium: The MIND randomized, placebo-controlled trial. Crit Care Med. 2010;38(2):428-437. HOPE-ICU Trial. Page VJ et al. Effect of intravenous haloperidol on the duration of delirium and coma in critically ill patients (Hope-ICU): a randomised, double-blind, placebo-controlled trial. Lancet Resp Med. 2013;1(7):515-523. AID-ICU Trial. Andersen-Ranberg NC et al. Haloperidol for the Treatment of Delirium in ICU Patients. N Engl J Med. Published online October 26, 2022. MIND-USA Trial. Girard TD et al. Haloperidol and Ziprasidone for Treatment of Delirium in Critical Illness. N Engl J Med. 2018;379(26):2506-2516. MENDS Trial. Hughes CG et al. Dexmedetomidine or Propofol for Sedation in Mechanically Ventilated Adults with Sepsis. N Engl J Med. 2021;384(15):1424-1436. SEDCOM Trial. Riker RR et al. Dexmedetomidine vs Midazolam for Sedation of Critically Ill Patients: A Randomized Trial. JAMA. 2009;301(5):489. MIDEX and PRODEX Trials. Jakob SM et al. Dexmedetomidine vs Midazolam or Propofol for Sedation During Prolonged Mechanical Ventilation: Two Randomized Controlled Trials. JAMA. 2012;307(11):1151. DahLIA Trial. Reade MC et al. Effect of Dexmedetomidine Added to Standard Care on Ventilator-Free Time in Patients With Agitated Delirium: A Randomized Clinical Trial. JAMA. 2016;315(14):1460. SPICE III Trial. Shehabi Y et al. Early Sedation with Dexmedetomidine in Critically Ill Patients. N Engl J Med. 2019;380(26):2506-2517. MENDS II Trial. Hughes CG et al. Dexmedetomidine or Propofol for Sedation in Mechanically Ventilated Adults with Sepsis. N Engl J Med. 2021;384(15):1424-1436. Pro-MEDIC Trial. Wibrow B et al. Prophylactic melatonin for delirium in intensive care (Pro-MEDIC): a randomized controlled trial. Intensive Care Med. 2022;48(4):414-425. Caffeine: The chemistry behind the world’s most popular drug Stephenson J. Nicotine and caffeine withdrawal may affect ICU patients. Nursing Times. June 2019 . RASS for Agitation Assessment CAM-ICU For Delirium Assessment Previous Next

< Back Abdominal Pain- Renal Disease A 72-year-old male with multiple medical co-morbidities presents with several weeks of right-sided abdominal pain. His family reports he hasn't been eating or drinking much. He has a slightly altered mental status and was unable to provide any more detailed history of his symptoms, such as aggravating/ alleviating factors or the relationship of his pain to meals. His medical history is significant for poorly controlled diabetes with neuropathy and renal insufficiency. He has not seen a primary care provider in over 6 months. On exam, he is uncomfortable but not in acute distress. His heart rate is in the 100s, and his blood pressure is normal. He is febrile to 101. He has dry mucous membranes. He has tenderness in the right upper quadrant with a positive Murphys sign. His exam was otherwise unremarkable. Workup? Imaging- right upper quadrant ultrasound Laboratory evaluation- CBC, basic metabolic panel, AST/ALT, bilirubin His labs are remarkable for mild leukocytosis and an elevated Cr (baseline 1.2, currently 2). Imaging was remarkable for cholelithiasis and gallbladder thickening. The EGS team is consulted and the patient is admitted to the surgical ICU given his acute on chronic renal insufficiency. What are the possible etiologies of his renal insufficiency and the initial treatment strategies based on the underlying cause? Pre-renal causes, such as hypovolemia, lead to decreased renal perfusion. Treatment involves volume repletion. Intra-renal causes, such as medication and acute tubular necrosis from sepsis, requires treatment of the underlying cause concurrent with volume repletion, treatment of electrolyte derangements and avoiding further nephrotoxin exposure. Post-renal causes, such as kidney stones or foley catheter malfunction, require relief of the obstruction. Based on the patient's history of decreased oral intake, he is at risk for acute hypovolemia, which can worsen his baseline chronic renal insufficiency. He was treated with volume resuscitation and close monitoring of his urine output. When should he undergo cholecystectomy? If cholecystitis was the precipitating cause, he would likely continue to worsen if his surgery was postponed. If hypovolemia was the precipitating cause, it would benefit from volume resuscitation, which can be administered throughout the operative course. If his renal insufficiency was not an acute change, and it was a slow decline since his last clinic visit, it was unlikely to significantly improve in a short time. The ICU team, EGS team and anesthesiology discussed the risks versus benefits of proceeding with surgery. Regardless of the etiology, postponing his surgery would be unlikely to improve his operative risk profile. We proceeded with laparoscopic cholecystectomy, and he returned to the ICU postoperatively for ongoing resuscitation and monitoring. Management of Renal Failure The causes of renal failure can be categorized into pre-renal, intra-renal, or post-renal. Acute infection can precipitate renal insufficiency, which is associated with poorer outcomes. Pre-Renal Caused by hypovolemia (dehydration) from decreased intake, nausea/ vomiting, excessive diuresis, third-spacing from acute inflammatory processes (pancreatitis), blood loss, inadequate replacement of insensible losses. The common final etiology in pre-renal causes is decreased renal perfusion. Treatment- volume replacement. Intra-Renal Multiple different intra-renal causes, including vascular or micro-vascular etiologies, glomerular disease, and interstitial disease (acute tubular necrosis, medications, and various precipitates such as myoglobin and crystals). The most common acute causes are medication and ATN from ischemic/ sepsis. Treatment involves management of the underlying etiology and supportive care. Post-Renal Caused by any obstruction from the renal pelvis to the urethra, including kidney stones, malignancy (can obstruct anywhere from the ureter to the bladder), retroperitoneal fibrosis, prostate enlargement, blood clots in the bladder or foley catheter malfunction. Treatment involves relief of the obstruction. Acute Cholecystitis with Renal Dysfunction Diabetes and severe cholecystitis (Grade III- organ dysfunction) are risk factors for increased mortality in patients with acute cholecystitis.[1] As noted in the discussion above, it is crucial to weigh the risks and benefits of operative intervention. If there is a modifiable risk factor, such as an acute cardiac event that is amenable to intervention. Escartin A et al. Acute Cholecystitis in Very Elderly Patients: Disease Management, Outcomes, and Risk Factors for Complications. Surgery Research and Practice. 2019;2019:9709242. Previous Next

< Back Diverticulitis...pending A 52-year-old female developed left lower quadrant abdominal pain, which she thought it was gas pain or indigestion. Unfortunately, the pain worsened and became so severe that she presented to the ER for evaluation. Associated symptoms include nausea, vomiting, lower grade fever and constipation. CBC revealed WBC of 13.5, renal panel was unremarkable. A CT of the abdomen/ pelvis with oral and IV contrast was obtained. CT Scan of Diverticulitis There was minimal thickening and inflammatory changes in the sigmoid colon. She was diagnosed with diverticulitis and discharged with a course of oral antibiotics. Over the next several months, she continued to have pain, with increasingly frequent and intense episodes. She was admitted to the surgery service several months later for a particularly severe episode. She was treated with IV antibiotics and then had resolution of her symptoms and was discharged home. What is the next step? Schedule for colonoscopy to rule underlying pathology. Discuss elective sigmoid colectomy for recurrent episodes of diverticulitis. The plan was to schedule a colonoscopy, but unfortunately, she never had a symptom-free interval. She returned several days later with recurrent pain. She was presented with the option of surgical intervention to remove the inflamed part of her colon. She underwent an uncomplicated laparoscopic sigmoid colectomy with primary anastomosis. Management of Diverticulitis Previously, antibiotics were recommended for the management of diverticulitis, regardless of severity. Two studies (AVOD, DIABOLO) have demonstrated no difference in outcomes for patients with uncomplicated diverticulitis that were managed with or without antibiotics.[1,2] Patients who have an episode of complicated diverticulitis (episode associated with free colon perforation, fistula, abscess, stricture, or obstruction) require an endoscopy to evaluate for underlying malignancy. Indications for Surgery Emergent surgery- acute episode with perforation or peritonitis. Semi-urgent surgery- failure of non-operative management (ie symptoms persist despite bowel rest and antibiotics). Elective colectomy - Resolved episode of diverticulitis associated with abscess/ fistula/ stricture/ obstruction. - Recurrent episodes of uncomplicated diverticulitis that interfere with the patient's lifestyle (frequent episodes, repeated hospital admissions, etc). For More Information on the Management of Diverticulitis ASCRS Patient Information: Diverticular Disease AVOD Trial. Chabok A et al; AVOD Study Group. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg. 2012;99:532–539 . Diabolo Trial. Daniels L et al; Dutch Diverticular Disease (3D) Collaborative Study Group. Randomized clinical trial of observational versus antibiotic treatment for a first episode of CT-proven uncomplicated acute diverticulitis. Br J Surg. 2017;104:52–61. Previous Next

1 < Back Textbooks General Surgery: Scientific Foundations Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 21st Edition, 2021. This is the detailed explanation of the science behind the practice of surgery. This is the basic science textbook I used during residency. Mulholland and Greenfield's Surgery: Scientific Principles & Practice. Previously known as "Greenfields". General Surgery: Beyond Basic Science Cameron's Current Surgical Therapy. 13th edition, 2019. Short chapters with high-yield information on every topic in General Surgery. Must-have for later in residency. Trauma Mattox Trauma. 9th edition, 2021. The trauma surgery bible. Highly recommend. Critical Care Marino ICU. 4th edition, 2013. The ICU bible. Highly recommend. Civetta, Taylor, & Kirby's Critical Care Medicine. 5th edition, 2017. A detailed explanation of physiology, diagnosis, and management. Finks Critical Care. 7th edition, 2017. Slightly less detailed than Civetta. Excellent book- not too simplistic and not painfully detailed. Evidence-Based Practice of Critical Care. 3rd edition, 2019. Reviews the literature regarding specific high yield critical care topics. Surgical Critical Care Therapy: A Clinically Oriented Practical Approach. 1st edition, 2018. Essentials of Mechanical Ventilation. 4th edition, 2018. Previous Next

< Back Stomach Ulcers UpToDate Patient Information Patient education: Peptic ulcer disease (Beyond the Basics) Patient education: Helicobacter pylori infection and treatment (Beyond the Basics) Patient education: Upper endoscopy (Beyond the Basics) Patient Information from Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Upper Endoscopy Previous Next

< Back Blast- Multiple Penetrating Injuries A 32-year-old male soldier sustained a severe blast injury with a chest wound and a supraclavicular wound, a tangential right shoulder wound, and right hand wounds. He arrives at the hospital for care. He was awake and alert, hemodynamically normal. A secondary survey revealed these wounds. Injury Pattern What are the possible injuries based on this wounding pattern? Intra-thoracic (cardiac, pulmonary), great vessels/ right subclavian vessels Next steps in evaluation? Extended FAST exam to evaluate for fluid in chest, abdomen, and pericardial space. CXR to identify for retained foreign body. Helpful to place radio-opaque markers on wounds to help establish trajectory. Plain film of chest/ upper abdomen What additional injuries are possible based on these wounds and imaging? Any organ in the path of the wounds can be injured- this includes intra-abdominal structures (small and large bowel, stomach, spleen, kidney), retroperitoneal structures (kidney) and the diaphragm. How do we determine which body cavity to explore first? Hemodynamic stability and wounding pattern can direct how to proceed. A hemodynamically unstable patient requires swift intervention concurrent with ongoing resuscitation, while a stable patient can be approached more deliberately. The clinical exam can suggest which body cavity is causing the instability. Peritonitis, abdominal distension, grossly positive FAST in the abdominal views suggest the abdomen as the site of injury. Signs of thoracic injury causing instability include decreased breath sounds, jugular vein distension, muffled heart sounds, fluid on pericardial view of the FAST fluid, and a large volume of bloody output in the chest tube. In addition, location of projectiles on plain film help determine trajectory, and any structures along the trajectory can be injured. This patient was managed in a deployed environment by an austere surgical team. We did not have access to CT imaging and we had limited capacity for continuous monitoring. Therefore, in order to rule-out cardiac and intra-abdominal injuries, we performed a midline laparotomy. We performed a pericardial window through the laparotomy. There was no fluid in the pericardium. We performed an abdominal exploration. There were no intra-abdominal injuries. Wounds in the Cardiac Box In the classic description, the “cardiac box” is bordered superiorly and inferiorly by the sternal notch and the xiphoid process, and laterally by the nipples. However, thoracic gunshot wounds outside these confines can just as readily result in a cardiac injury. The diagnosis of cardiac injuries starts with a physical exam and FAST. Physical exam findings can include hemodynamic instability, muffled heart sounds, and jugular venous distension (Beck's triad). FAST will reveal pericardial fluid. If the patient is awake, they may be panicked and have an impending sense of doom. Penetrating cardiac injuries require operative repair. FAST Examination Online Tutorial Society for Academic Emergency Medicine SAEM FAST Exam YouTube Video Previous Next

[Editorial inspired by @kari_jerge] Why Don't They Believe Us? < Back [Editorial inspired by @kari_jerge] Seen on Twitter recently: Troll: I demand pictures of your full ICU to prove to me it’s full Female surgeon: None of us owes you a damn thing. Especially not pictures that will get us fired. But I’ll get right on that… What do you do if you accidentally injure yourself while working or making home improvements? Do you call 911 or have someone drive you to the ER? What do you do if you have high blood pressure, or diabetes, or depression? Do you go to a primary care doctor? What do you do if you have severe arthritic hip pain that doesn't resolve with conservative (non-operative) management? Do you consider talking to an orthopedic surgery about a hip replacement? I don't know what portion of the population inherently trust the medical community, but for the remainder of this editorial, I will presume that it's a majority. For those that don't, this doesn't apply. If you don't trust modern medicine, I won't convince you that you should trust our reports about this pandemic. Let's assume you accept modern medicine, including visiting the emergency department, having a primary care doctor, taking prescription medicine, and any of the other various diagnostic tests, consultations, and treatments. If this is the case, why would you think we would voluntarily try to deceive you about the capacity and occupancy of our ICU facilities? Why would so many medical community leaders actively speak out with a nearly singular voice to spread a lie? Ranging from the widely known Dr. Sanjay Gupta to a wide assortment of medical providers in many specialties. We have nothing to gain from building this whole façade. This isn't just a few people speaking up. This is a monumental effort to warn people. Social media has given a voice- and many have worked very hard to dispel the myths spread by many loud voices that continue to spread falsehoods. We have nothing to gain. You trust us to save your life when you have a heart attack, need emergency surgery, or care for you when you're severely ill from any matter of diseases. We haven't changed as a community to collectively spread these myths. It really is as bad as we say. We genuinely don't get paid more for patients who die from COVID. We don't have adequate PPE. We aren't lying. If you continue to deny reality, we will still care for you or your family and friends, in the unfortunate case you become ill, because that's what we do. We are just hoping that we will have the resources you need. And if we stretch our personnel any thinner, we will not have enough nurses and providers to care for you. We are the last hope. Don't make choices you'll regret. Previous Next

7 When The Scientific Secrets of Perfect Timing - We should capitalize on our natural circadian rhythms. What is your chronotype? - Premortem. Examine what you think could go wrong. Not getting a book written. Think of what could cause it. Not writing every day. Not keeping the editor updated. Think of how to change those to positive actions. He wrote six days a week and consulted his editor regularly. - Techniques for promoting belonging in your group? Email response time is the single best predictor of whether employees are satisfied with their boss. - Syncing to the heart- working in harmony with others makes it more likely we will do good. Previous Next

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

What is ACS? A day in the life of an Acute Care Surgeon. FAQs. ICU Rounds. Trauma Surgery. Acute Care Surgery What is Acute Care Surgery? Medicine, particularly surgery, has become increasingly specialized, with providers developing progressively narrower expertise. Previously, surgical critical care fellowship was the primary pathway for specialization in the management of critically ill and injured patients. Management of "sick" surgical patients, regardless of the underlying surgical etiology, requires flexibility in addition to width and breadth of knowledge to manage a wide spectrum of clinical challenges, including deranged physiology and complex surgical pathology. Balancing an acutely hemorrhaging patient, an elderly patient with severe poly-trauma, a ventilator-dependent patient with an acute abdomen...the list is endless. Acute Care Surgery (ACS) was brought about to ensure that there is access to a specialized physician that can manage a spectrum of critically ill patients, including trauma, emergency general surgery (EGS), and surgical rescue . Surgical rescue involves the management of procedural complications or clinical situations that require emergent surgical intervention: "airway emergency, hemorrhage, intestinal obstruction, perforated viscus, tube/line/device dysfunction, uncontrolled sepsis with a surgical etiology, visceral ischemia, and wound complication." Management can include the following interventions: "airway intervention, biliary repair/ reconstruction, bowel resection, hernia repair, hemorrhage control, source control of infection, surgeon-guided resuscitation, tube/line/device repair, and wound debridement."(1) Pillars of Acute Care Surgery 1. Kutcher ME et al. Surgical rescue: The next pillar of acute care surgery. J Trauma Acute Care Surg. 2017;82(2):280-286. 2. Kutcher M.E., Peitzman A.B. (2017) A History of Acute Care Surgery (Emergency Surgery). In: Di Saverio S., Catena F., Ansaloni L., Coccolini F., Velmahos G. (eds) Acute Care Surgery Handbook. Springer, Cham. Who Is Our Patient Population? Read More A Day in the Life of an Acute Care Surgeon Read More What happens during Surgical ICU (SICU) Rounds? Read More Who is on the Trauma Team? Read More What happens in the trauma bay? Read More The Trauma Bag Read More Frequently Asked Questions Read More Definitions Read More More Information on Acute Care Surgery Read More