< Back ICU Rounding: How I Do It The ICU can be intimidating. Critically ill patients are often surrounded by machines (ventilators, dialysis, etc) and IV poles, with multiple lines and catheters extending from their face, chest, abdomen, neck, and groin. A standardized approach can help the team synthesize and interpret all the subjective and objective data to establish a diagnosis and devise a treatment plan for these complex patients. Rounding in the ICU is different from rounding on floor patients. Floor patients are typically presented in a problem-based format- they are likely to have a short list of active issues being addressed, often just one diagnosis (cholecystitis, bowel obstruction, colon cancer status-post colectomy). Patients can certainly have co-morbidities, such as diabetes and hypertension, but they are usually relatively straightforward. Presentations are briefer than ICU presentations, and largely focus on the acute surgical diagnosis. Here is an example of a surgical floor patient. 32 year old female, hospital day 2 following laparotomy for small bowel obstruction. Her pain is controlled with oral analgesics with minimal prn requirements. She is hungry and passing flatus. She is using her incentive spirometry and ambulating. She has had minimal output in her nasogastric tube. Staples are intact along her midline laparotomy incision with no surrounding erythema and appropriate peri-incisional tenderness. Labs are only remarkable for some mild hypokalemia with K 3.4. She is voiding spontaneously with adequate urine output. Plan to replete potassium, remove NGT and advance diet. In contrast, ICU patients are fragile with more physiologic derangements that threaten homeostasis. Critical illness can profoundly impact multiple organ systems and the interdependence of organ systems adds another layer of complexity. Patients can be presented in a problem-based format, like floor patients, or a system-based format. There are pros and cons to each. As mentioned, a problem-based format addresses each diagnosis (for example- cholecystitis, bowel obstruction, heart failure, pneumonia, ileus). In contrast, a system-based format addresses each organ system (for example- cardiac, pulmonary, renal, neurologic). Problem-based might seem easier on first glance, but one downside in the ICU setting is the risk of overlooking organ systems without a discrete disease process. One downside of the system-based format is the categorization of one diagnosis to various organ systems. For example, ventilator-associated pneumonia is related to the pulmonary system but overlaps with infectious disease. However, the system-based format is comprehensive and thorough, which helps ensure that all physiologic processes are considered. One advantage of the system-based format is it’s adaptability to less complex patients. While it’s challenging to apply floor round formatting to the ICU setting, once you understand how to utilize the ICU system-based model, you can use it to briefly review non-ICU patients to ensure that you don’t forget something. For a young male with cholecystitis, you don’t need to report GCS, medication infusion rates, ventilator settings, insulin requirements, etc. But the systems are still pertinent- address pain (neuro), ensure normal vitals (cardiac) and use of incentive spirometer (pulmonary), check oral intake, assess return of bowel function and examine wounds (GI), inquire about adequate urination and review BMP (renal), ensure no fever, review CBC (heme and ID), and ensure ambulation/ SCDs (prophylaxis). ICU care is a team endeavor, requiring the integration of nursing, respiratory therapy (RT), dieticians, pharmacists, physical therapy and other team members to provide comprehensive care. ICUs must implement a system to integrate care plans between all team members. This can occur in different formats, either with “prerounds” (brief discussion with multidisciplinary team about each patient before formal rounds) or with multidisciplinary rounds (team members present their key data points/ plans in a structured format). One example of multi-disciplinary rounds (abbreviated): resident reports one-liner (see example below); nurse reports their assessments (pain/ sedation scores, delirium assessment, etc); RT reports current ventilator settings, results of spontaneous breathing trials and respiratory treatments; the resident then presents the patient as below. Order of Presentation during Rounds 1. Brief one-liner [presented by the resident, APP or student caring for the patient]. See below. 2. Bedside nurse- report on sedation, pain, infusion rates, etc 3. Respiratory therapy- report on ventilator settings, respiratory interventions, etc 4. Formal patient presentation [presented by the resident, APP or student caring for the patient]. See below. 5. Pharmacist- review of medications, including potential dose adjustments, antibiotic tailoring, etc 6. Attending 7. FAST-HUG- ensure that key aspects of care are addressed (feeding, analgesia, sedation, thromboprophylaxis, head of bed elevated, ulcer prophylaxis, glycemic control) 8. Readback- nurse briefly summarizes the key goals of the day One-liner: brief patient history, acute overnight events. Example: 32 year old male, POD 7 exploratory laparotomy following motor vehicle collision, remains intubated for VAP. Formal Patient Presentation [Systems Based] Neurologic (Neuro) Diagnosis: Exam/ objective data. GCS, reflexes, pupils. ICP monitor. Medication: continuous infusions, requirements of prn analgesics Plan: Neuro- patient remains intubated and sedated, GCS 11T off sedation, currently on Fentanyl @ 100 mcg/ hr and propofol @ 20. Minimal requirements of prn analgesics. We will wean fentanyl infusion and use enteral multi-modal analgesia. Cardiac Diagnosis: Exam/ objective data. Vitals: describe the trend, know when outliers occurred (for example, an isolated heart rate (HR) of 130 during a procedure at noon the previous day is different from a sustained HR of 130s). If patient has any invasive monitoring, such as arterial pressure waveform analysis (FloTrac, Vigileo), pulmonary artery catheter or central line, include these as well. Medication: Plan: Cardiac: HR 90s-100s, Flotrac shows normal SVV. On norepinephrine, requirement is currently down to only 2 from a max of 10 yesterday, MAP goal of >65. Continue to wean norepinephrine. Remove arterial line once off norepinephrine for 12 hours. Pulmonary (Pulm) Diagnosis: Exam/ objective data: intubated, secretions, breath sounds, breathing pattern. Ventilator settings. Labs: ABG if performed. Imaging: note findings, and describe how it’s changed relative to prior imaging Medication: Plan: Example: Pulm- pt remains intubated, current ventilator settings. CXR still shows bilateral fluffy infiltrates. *on antibiotics day x of x for VAP, CXR worsening/ stable, secretions improving. Then, later: ID- patient is on antibiotics day x of x for UTI, and day x of x for VAP. Gastrointestinal (GI)/ Nutrition Diagnosis: Exam/ objective data: abdominal wounds, drains, stool management system, bowel function, nutrition. Medication: bowel regimen Plan: GI- patient started on tube feeds two days ago, but he’s having minimal stool output. Abdomen is distended and tympanitic. We held feeds this morning and have an abdominal plain film pending. Renal/ Fluids/ Electrolytes (Renal) Diagnosis: Exam/ objective data. IV fluids. Intake/ output. BMP. Medication: Plan: Renal- foley in place with good urine output, I/O 3.2L/2.9L. No continuous IV fluids. Electrolytes within normal limits. Hematologic (Heme) Diagnosis: Exam/ objective data. Labs: Hgb, Plt. Transfusion. Medication: Plan: Heme- stable mild anemia, checking CBC every Monday/ Wednesday/ Friday. Infectious Disease (ID) Diagnosis: Exam/ objective data. Labs: WBC, neutrophils. Culture results (sample source, date, results). Medication: current antimicrobials. Plan: ID- patient is on antibiotics day 2/5 for UTI, and day 2/5 for VAP. He has remained afebrile for the last 48 hrs. His WBC is downtrending. No pending cultures. Endocrine (Endo) Diagnosis: Exam/ objective data. Labs: glucose trend, insulin requirements Medication: Plan: Endo- stress hyperglycemia, glucose range from 210-240. Currently on SSI with 24 hr requirement of 22U. Increase to more aggressive sliding scale, but holding off adding scheduled/ basal insulin while adjusting his enteral nutrition. Prophylaxis/ Lines and Tubes GI prophylaxis DVT prophylaxis Location/ date of invasive lines and tubes Patient is on IV PPI for ulcer prophylaxis, on enoxaparin BID. PICC RUE, day 10. Foley, day 5. Helpful hints: - Be succinct and synthesize the data. Have all the information available if asked, but don’t report every single bit of data. - Some problems can be relevant to multiple systems. For example, ventilator-associated pneumonia is related to the pulmonary system but overlaps with infectious disease. You can pick one system to discuss it, but you can also briefly mention it in the other relevant system. For example: Pulmonary- patient remains intubated, on antibiotics day x of x for VAP, CXR worsening/ stable, secretions improving. Then, later: ID- patient is on antibiotics day x of x for UTI, and day x of x for VAP. - If the patient’s BMP is normal, you can state that instead of reading every value. If there is one lab value that is abnormal but the remainder is normal, you can say “normal except for [elevated potassium of 5.5]” - Be thoughtful about ordering labs and imaging. Daily CXR purely because a patient is intubated for a bad TBI is not necessarily helpful. Even if the patient is being treated for pneumonia, daily CXR is unlikely to change your management unless there is a clinical change. CXR is appropriate if there are specific interventions that were performed or if the patient has a clinical deterioration- for example, following placement of chest tube for pleural effusion, following 24 hours of aggressive diuresis, for evaluation of acute dyspnea/ hypoxia. - Don’t repeat information presented by other team members- if the nurse has already provided infusion rates or RT has already provided ventilator settings, just move through the next part of the presentation. ICU Rounds .pdf Download PDF • 46KB A-F Bundle .pdf Download PDF • 33KB Previous Next

< Back The Trauma Bag Why was there a need for a trauma bag in the hospital? As an acute care surgeon responding to trauma activations, airway emergencies, and a variety of other hospital surgical emergencies, there are a handful of supplies that I always have with me. The two basics are a scalpel for surgical airways and trauma shears (classically used to remove clothes in the trauma bay, but I seem to find more uses all the time). Eventually, I added a Kelly clamp to my armamentarium- handy for disconnecting or unscrewing a wide variety of impossibly tight connections or securing something in place. During the COVID Pandemic, numerous changes were made in our hospital to minimize infection transmission. Unfortunately, several of the modifications had unintended negative consequences. When we stopped wearing white coats, we lost our pocket space for stashing scalpels and shears. We also carried more gear, including eye protection and N-95 masks (carried in a brown bag when not worn). Many surgeons adapted by using an assortment of bags, such as sling backpacks or CamelBak cases. My own choice is this fanny pack , which draws many compliments! The next challenge was the relocation of supplies from the wall of our trauma bay onto shelves in the hallway. Team members had to leave the trauma bay, locate which cart the item was on, and then scan for the item, which created delays. This disrupted communication as well because team members missed changes when they were outside the room. Another hurdle that existed even before the pandemic was the array of different names for the same item. Most people who place cotton-tipped applicators in their ears after their shower call them by the brand name “Q-tip”…they are actually called “cotton tip applicators” or “CTA”. **Note- don’t use Q-tips in your ears!** Drop the Q-tip! Why ENTs are begging you to leave your ears alone. The surgeon might ask for 4x4s, which is what we call gauze in the operating room. Some say "Quik-Clot” while others know the product by the name “Combat Gauze”. Sutures are a whole other bag of worms…do you use silk or Ethibond to secure your chest tube? Curved or straight needle? Countless times, the trauma chief is managing the trauma and when someone calls for a suture, their attention is often diverted to advising the person reaching into the suture box on the wall.…"no, the one to the left, top row." It’s not always easy to tell from the box what the suture and needle look like. In addition to the elimination of white coats, relocation of commonly used supplies outside the trauma bay, and different names for supplies, I noticed that several key items were frequently used and they seemed to be unreasonably challenging to locate in a timely fashion. Combat Gauze, Coban, specific suture on a specific needle, etc. Therefore, I created a backpack of supplies that I carry when on call. What does this bag do? This bag was created from my perception of a necessity to ensure specific supplies are readily available when responding to surgical emergencies. A Level 1 trauma center is equipped with the highest level of resources and personnel to manage the most complex patients, and our resources and patient population dictate what supplies are needed on a routine basis. My focus was on supplies that are (1) frequently used, (2) unique and not readily available in all locations where they are used, and when they are required, (3) delays in employment are remarkably morbid, and (4) portable. Why didn’t I include tourniquets? They’re frequently used and delays in employment are morbid, but patients typically have them in place on arrival and if not, they are readily available in the trauma bay. Why didn’t I include chest tubes? They are frequently used and delays in employment are morbid, but they are relatively widely available. In addition, the life-threatening physiology of hemothorax or pneumothorax can be resolved with a finger thoracostomy using a scalpel and Kelly (essentially the same process as placing a chest tube, but stopping at the step of a finger sweep in the thoracic cavity, releasing massive hemothorax or tension pneumothorax). Why didn’t I include a REBOA kit? This is a controversial topic. However, in the situation where resuscitative thoracotomy is deferred in favor of REBOA, rapid employment is ideal. However, this device is not frequently used at our facility. Paper clips? In a trauma bag? Yes, paper clips. They are used to mark wounds for creating a road map of the trajectory. What DOESN’T this bag do? This is NOT an all-inclusive bag for responding to all emergencies. It should not be considered a guide for pre-hospital emergency response, non-surgical emergencies, or any situations outside of the specifications reviewed above. There are other response teams in the hospital that have different supplies. For example, we have ICU nurses that respond to rapid response or code blue situations, and they carry critical care transfer bags. I don’t know the list of supplies that they carry, but here is a sample of potential contents of a “transfer bag”. In summary, my trauma bag is focused on specific needs that I perceived based on my daily work at my facility. If you perceive a need for a similar tool at your facility, I would encourage you to develop a supply list tailored to your needs. Trauma Bag- Supply List Personal Protective Equipment Blue gown, non-sterile (2) Medium gloves Mask with eye shield (1) Sterile Supplies for Procedures Pack of blue towels (1) Stapler (1) Sterile gown (1) Small Chloraprep (2) Laceration tray (1) Dressings and Hemostatic Agents Gauze, 4x4 (2) Surgicel, 2 in x 3 in (4) Quik-Clot, 3 in x 4 yds (3) Kerlix, 3.4 in x 3.6 yds (3) Kerlix, 4.5 in x 4.1 yds (1) Coban, 4 in x 5 yds (1) Large Tegaderm (4) Sutures and Instruments #1 Ethibond, curved needle (8) #0 Silk, straight needle (4) #0 Silk, curved needle (1) #2-0 Silk, curved needle (2) #2-0 Vicryl, curved needle (5) Skin stapler (1) Adsons (1) Kelly clamp (2) Needle driver (1) Laceration tray (1) Scalpel #10 (1) Scalpel #11 (1) Miscellaneous Cotton tip applicators (3) Tongue Depressors (2) Paper clips Disclaimer: This was created early in the pandemic, while I was a fellow at a different institution. Previous Next

6 Note Templates Trauma Admit Note Template .pdf Download PDF • 31KB ICU Progress Note Template .pdf Download PDF • 21KB ICU Rounds Sheets .pdf Download PDF • 46KB Extubation Note .pdf Download PDF • 30KB

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

14 Scienceblind Why Our Intuitive Theories About the World Are So Often Wrong Intuitive theories- our best guess as to why we observe the events we do and how we can intervene in those events to change them. Infer causality from our observations. Similar to historical theories- how we used to understand things before we had the ability to understand the reality (like heat as an “object” versus “energy”). Emergent process- system wide (no clear cause/ effect explanation), equilibrium-seeking, simultaneous, ongoing. Heat, weather, evolution are all emergent processes. Molecular theory, scientific theory. Holistic theory- matter is continuous and has heft and bulk Intuitive theories of the physical world Matter- substances are holistic and discrete, instead of particulate and divisible. Conservation- clay flattened, water poured from short fat glass to tall skinny glass. The difference between weight and heft, volume and bulk? Energy- heat, light and sound viewed as substance instead of emergent property. Why can you touch the 400 degree air in the oven but not the pan itself (without oven mitts)? The pan transfers heat better than air. How do we change from viewing “sound” as an “object” to viewing it as “energy”? First, we stop attributing permanence (noise doesn’t continue forever), then weight (clock doesn’t become lighter with each chime) and then mass (noise can pass through a wall, doesn’t have to maneuver around wall). Extra-missionist- rays go out of the eye and then return to create vision vs intro-missionist- rays enter the eye to create vision. Gravity- weight is an intrinsic property of objects instead of relation between mass and gravity. Objects don’t fall because they’re heavy- they fall when they don’t have upward force on them that exceeds gravity (center of gravity). Motion- force is something transferred between objections (“impetus”), instead of external factor changing the objects motion. What path will an object take- for example, a ball in a spiral slide- takes straight path after exiting, doesn’t gain an inherent “spiral” motion. Cosmos- earth is a motionless plane orbited by the sun. Changing of the tides, seasons (tilt of the earth as it revolves around the sun, the side closest to the sun is summer). Earth- continents and mountains are eternal and unchanging vs transient/ dynamic. Tectonic plates- similar land features on different coasts. Greenhouse effect and global warming- humans causing it, but the earth will live beyond us. Vitalism- living things possess an internal energy, or life force, that allows those things to move and to grow. Essentialism is the idea that an organism’s outward appearance and behavior are products of its inner nature, or “essence.” Intuitive theories of the biological world Life- animals viewed as psychological agents vs organic machines. Death= cessation of biological processes. Growth- eating is for satiation rather than nourishment, aging is a series of discrete changes vs continuous change. Vitalism- living things possess an internal energy, or life force, that allows those things to move and to grow. Essentialism is the idea that an organism’s outward appearance and behavior are products of its inner nature, or “essence.” Inheritance- parent-offspring resemblance viewed as nurture, vs transfer of genetic information. Illness- disease is due to supernatural causes, instead of microorganisms. Adaptation- evolution is the transformation of an entire population (butterflies become slightly darker with each generation) vs selective survival (darker butterflies survive to reproduce). Ancestry- species develop linearly (monkey→ ape→ human) rather than branching from common ancestor. Previous Next

1st day in radiology: your right is your left, your left is your right Radiologic Dyslexia < Back 1st day in radiology: your right is your left, your left is your right I have recently coined a new phrase. While showing my mom a picture, pointing out someone she had never met before, I commented, "he's the one on the right." Funny story, though- he was actually on the left side of the picture. I had to pause while I talked to my mom and reassure her that I know the difference between my right and my left. While scrolling through Twitter the other day, I was reviewing a question posed about an abdominal x-ray. Another Twitter user added a helpful hint by indicating "the right side of the circle" when pointing out an abnormality. I predicted he meant anatomical right (meaning the image's left side) based on my interpretation. We chuckled about the discrepancy between radiographic laterality and left-right differentiation in real life. I decided to designate this mix-up "radiologic dyslexia." Feel free to use this in the appropriate context! 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

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

1 A Field Guide to Lies Critical Thinking in the Information Age - Explains common misuses of statistics and misrepresentation of probability. Use common sense as the first line of defense. This impacts advertising, criminal trials (what is the likelihood that the defendant is guilty based on the blood found at the scene vs whats the possibility that any other individual is guilty based on the blood found at the scene). - Post hoc ergo propter hoc- After this, therefore because of this. Because this event followed another event, the subsequent event must have been caused by the first event. We link events that might be temporarily related but aren't actually cause and effect. - Likelihood of two unrelated events both happening= probability of event 1 x probability of event 2→ lower than the probability of each event independently. Likelihood of flipping one head on a coin followed by flipping another head. - Likelihood of two related events- for example, the likelihood of freezing weather tonight and tomorrow night→ higher given the occurrence of freezing weather the first night. - Vaccines lead to autism? People look at the increased percentage of autism diagnoses. Autism was more frequently diagnosed because it became more understood. Autism is commonly diagnosed between 18-24 months and the MMR vaccine is given around 12 months. - Was 9/11 an inside job? Why did the towers collapse vertically? Easy to overwhelm with questions and theories designed to cast doubt on the events. But structural engineers never found anything suspicious about it. - Breast cancer. Pretest probability- occurrence in the population. 1/8 women develop BrCA. Mammograms can over-call diagnoses (false positive). - Positive test + confirmed diagnosis= true positive - Negative test + confirmed absence of diagnosis= true negative - Positive test + confirmed absence of diagnosis= false positive (low FP= high specificity) - Negative test + confirmed diagnosis= false negative (low FN= high sensitivity) Previous Next

11 Made to Stick Why Some Ideas Survive and Others Die 6 Principles of Sticky Ideas - Simple - Unexpected- crash at the end of the car commercial. - Concrete - Credibility- the ability to test. Before you vote ask yourself if you are better off today than you were 4 years ago- Reagan. - Emotions - Stories Curse of knowledge- we find it hard to imagine not knowing what we have learned. Can’t imagine what it’s like not to understand a certain concept that we accept as fact Previous Next

< Back Guts on the Floor and Exposed Spine Patient #1 A 32-year-old male was involved in a head-on motor vehicle collision. He was ejected and pinned between two vehicles. He was brought in by EMS and on arrival to the trauma bay, he was covered with a sheet. When he was transferred to the gurney, it was clear that there was something unusual. He was eviscerated with a large wound in his right lower abdomen just above his inguinal ligament, and his intestines were entangled in his clothing. Patient #2 A patient was brought in by EMS following a motorcycle accident with a report of "exposed spine". Primary survey unremarkable, hemodynamically stable. FAST revealed fluid in the abdomen. A secondary survey revealed multiple extremity abrasions. When the patient was log rolled, he was noted to have a full-thickness degloving injury of the soft tissue and partial avulsion of the back musculature with exposed spinous processes. What are the management priorities? Prioritize primary and secondary survey, treat life-threatening injuries first. Secure airway. Evaluate for concomitant injuries, including thoracoabdominal injuries, requiring emergent surgical intervention. The challenge of Distracting injuries Remember- very painful or frightening injuries may distract from pressing clinical priorities. Regardless of how horrifying or novel an injury is, the goal of rapid evaluation and management of trauma patients is to identify and treat the most life-threatening injuries first. Remember to evaluate the airway, breathing, and circulation, and don't be concerned with the exposed intestine until you have ensured the patient doesn't have a pending loss of airway, tension pneumothorax, cardiac tamponade, etc. Control active arterial hemorrhage. Don't let the patient die from an unsecured airway while you are frantically attending to grass and flecks of wood and rock covering the exposed back muscle overlying the spine. Previous Next

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