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< Back Interpreting Chest X-Rays Developing skill with radiographic interpretation requires practice. Look at every film for your patients. Practice by looking at normal films, then compare between normal and abnormal. For example, compare an image for a patient with a normal cardiac silhouette and compare it with a patient with an abnormal silhouette with a widened mediastinum. This is NOT an exhaustive list of everything that can be seen on a chest x-ray, but is an overview of common pathology that can be seen. How to read a film 1. Identify- correct patient/ date/ time. 2. Identify orientation. Is the projection posterior-anterior (PA) or anterior-posterior (AP)? Is the patient rotated? PA is when the patient stands with their chest facing the x-ray cassette and the x-ray is behind the patient, so the x-ray beam travels from the posterior of the patient toward the plate, which is situated on the patients anterior surface. AP is when the patient’s back is towards the board and the x-ray is in from front of the patient, so the x-ray beam travels from the anterior of the patient toward the plate, which is situated on the patient’s posterior. This is the orientation when a patient is laying supine in the trauma bay. On an AP film, the heart appears enlarged compared to the PA. Rotated- compare bilateral or midline structures, such as clavicles and the spinous processes of the vertebra. If the clavicles are asymmetric or the spinous processes are not midline, the patient is rotated. Structures (ABCs) 1. Airway Is the trachea midline? Are there any opacities in the lung fields- pneumonia, masses, bilateral haziness? Do the lung markings extend to the edge of the chest? If not, and the space area is dark, this is suggestive of a pneumothorax. In contrast, if the space is white, this is suggestive of a fluid collection (hemothorax, infected fluid, etc). Is there evidence of fluid? This depends on the patient’s postion and the consistency of the fluid. Free fluid (fresh hemothorax, pleural effusion) will layer dependently, so if the patient is upright, the costophrenic angles will be blunted. If the patient is supine, the fluid can cause generalized opacity of the lung field because it layers along the back of the patient. 2. Bones- examine for fracture, dislocation, masses (tumor) Upper extremity/ shoulder? Ribs? Vertebra? 3. Cardiac Silhouette size/ contour? Normal is <1/2 the size of the thoracic cavity Evidence of aortic injury? *Bonus- 3 places for blunt aortic injury- aortic root, diaphragm, and isthmus just past subclavian takeoff Widened mediastinum (supine >8 cm or upright > 6cm) Loss of aortopulmonary window Abnormal aortic contour Depressed left mainstem bronchus Left apical capping Left hemothorax Nasogastric tube deviation Widened paraspinal or paratracheal stripe 4. Diaphragm Elevated- symmetric elevation is consistent with poor inspiratory volume. Blunting of costophrenic angle- effusion. Abdominal contents in chest (ie gastric bubble in the left chest)- consistent with diaphragm injury or defect. 5. Everything else Air in soft tissue- many potential etiologies, but common causes include pneumothorax or esophageal/ airway disruption. Air under the diaphragm (pneumoperitoneum)- concerning for hollow viscus injury. Iatrogenic foreign bodies- endotracheal tube, central lines, ports, pacemaker, endovascular grafts, esophageal stents, feeding tubes Non-iatrogenic foreign bodies- swallowed objects Additional References and Images from Radiopaedia.org **Click on Cases and figures and Imaging differential diagnosis on the right-hand column of each page for more in-depth explanations of specific pathology** Radiopaedia Airway Bones and Soft Tissue Cardiac Silhouette and Mediastinum Widened Mediastinum Hemothorax Pneumothorax Nasogastric Tube Position Previous Next

< Back Who is on the Trauma Team? This can vary by institution and by the severity of the anticipated trauma (Code 1 or 2, etc), but I have an tried to include all the potential participants. Please note, all members of the team are crucial to an effective and timely resuscitation. Roles and Responsibilities - Team leader- directs/ coordinate the trauma resuscitation. Typically stands at the foot of the bed so they can see the whole picture. Assist when advanced procedures are indicated, such as resuscitative thoracotomy. This role can be filled by a member of the surgery or emergency medicine team (chief resident). - Primary examining provider- performs primary/ secondary survey. Perform interventions including chest tubes, central lines. This role can be filled by a member of the surgery team or emergency medicine team (intern, resident, APP). - Airway- this role can be filled by a member of the emergency medicine team (senior resident) or anesthesia (CRNA, anesthesiologist). - Nursing- establish intravenous access, draw blood for labs, place monitors, administer medication, place foley catheter. - Writer/ scribe- creates chronological record of interventions (medication, procedures), exam findings announced by the examining physician. - Respiratory therapist- assist with establishing mechanical ventilation if needed. - Radiology technician- assists with obtaining rapid portable images. Other team members - Trauma attending- support the trauma chief, ultimately in charge of critical decisions such as proceeding to the operating room. - Trauma/ ACS fellow- functions as junior faculty, training to fill the role of trauma attending. - Emergency Medicine attending- support the emergency medicine residents, whichever role they are filling (airway, team leader, procedures, FAST). 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

< 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

About Doc on the Run About Doc on the Run Active Duty Army Acute Care Surgeon. Nomad. Runner. Music aficionado. Culinary amateur. Intermediate-level technology nerd. Christian. Inquisitive life-long learner. My primary passion is surgery, and my life has been dedicated to becoming a trauma surgeon. After graduating high school at 17, I attended the University of Missouri, Kansas City, a six-year medical school. I was commissioned in the Army and completed 6 years of General Surgery residency in Augusta, Georgia. Board-certified in General Surgery. For 3 years, I was a staff General Surgeon in North Carolina and deployed to Iraq, Kuwait, Jordan, and Africa. Board-certified in Surgical Critical Care and completed a two-year AAST Acute Care Surgery fellowship in North Carolina. I spent two years in San Antonio, Texas, and then 1 year in South Korea, where I finished out my career on Active Duty. Photo courtesy of JW, 2013

< 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 Pain and Anxiety...pending Management of Pain and Anxiety Previous Next

< Back Who Is Our Patient Population? We take care of critically ill and injured patients. Here are just a few examples of the different patient scenarios we manage. We are available 24 hours a day, 7 days a week. Therefore, we often receive consults for various other surgical disease processes outside of what is listed here. Trauma Penetrating wounds from gunshot wounds, stabs, or assaults from any material that breaks the skin and causes bleeding or significant tissue damage Blunt injuries from falls (roof, ladders, etc.), motor vehicle accidents, bicycle accidents, pedestrians struck by vehicles. Non-accidental injuries (abuse, inter-personal violence) Surgical Critical Care Critically ill trauma or emergency general surgery patients. Patients undergoing complex or high-risk surgical procedures or requiring intensive care unit (ICU) admission. Complications from procedural interventions. Intra-abdominal catastrophes. Airway emergencies- patients who are unable to be intubated and require a surgical airway. Emergency General Surgery Appendicitis, Cholecystitis, Diverticulitis. Bowel ischemia or bowel obstruction. Soft tissue infection- necrotizing soft tissue infection. Surgical airway or enteral access- tracheostomy for ventilator dependency and percutaneous endoscopic gastrostomy (PEG). Previous Next

< Back Unusual Case of Peritonitis A 23-year-old male presents to the ED with several days of abdominal pain. He is otherwise healthy and denies any other symptoms. On exam, he has diffuse peritonitis, but no other obvious findings. He is tachycardic with a heart rate in the 110s-120s. His blood pressure is 100s/60s. No significant medical or surgical history. No remarkable events recently. He had plain films of his chest and abdomen. Plain film of the chest and upper abdomen What's going on? Differential diagnosis? Perforated hollow viscus- gastric or duodenal ulcer, bowel obstruction leading to perforation, procedural complication (EGD, ERCP). On further questioning, the patient endorses a recent soccer game during which he blocked a goal and was hit in the stomach. Unsure if it was the soccer ball or a kick to the stomach. He then had a CT of his abdomen and pelvis. CT of the abdomen and pelvis, representative slices What's going on? Diagnosis? Intervention? Free air (pneumoperitoneum) and free fluid are consistent with a perforated hollow viscus. No clear source on the CT. This requires abdominal exploration. We proceeded with exploratory laparotomy. Found liters of succus. There was a single perforation of the small bowel that was resected and anastomosis was performed. The abdomen was closed and a drain was placed. Intraoperative Findings Management of Peritonitis from Perforated Hollow Viscus The hollow viscus refers to the gastrointestinal tract from the esophagus to the rectum. Pain associated with hollow viscus perforation is classically acute onset, constant, severe, and worse with movement. The peritoneal lining of the abdomen becomes inflamed in reaction to the leaking enteric contents. This is a surgical emergency. The diagnosis can be made with the visualization of pneumoperitoneum on an upright chest x-ray (lucency under the diaphragm). A patient with peritonitis and free air requires surgical exploration. A CT scan can help identify the underlying pathology, but is not mandatory and should not delay operative intervention. Non-operative management is reserved for the patient with a sealed perforation (example- retroperitoneal duodenum) or a patient who is a prohibitively high-risk operative candidate (example- patient on palliative or hospice care). Cultural differences Not all cultures have adopted the practice of Western medicine. In some cultures, people still seek advice and medical care from traditional healers. Unfortunately, this can delay treatment if a patient requires operative intervention. Some of the treatments provided by traditional healers can also lead to further injury. This patient with a small bowel injury was seen by a traditional healer several times before he was finally brought to the hospital. The marks on his skin are the result of a practice of cutting the skin to heal the cause of his abdominal pain. Another patient was brought to the hospital for a severe infection of his genitalia. By the time he came to the hospital, his infection was so extensive that he required a debridement of a large portion of the skin in his perineum. He had been seeing a healer who was treating him with a topical solution that had essentially burned his skin, so in addition to the underlying infection, he had severe tissue damage. Previous Next

Common Measurement Conversions < Back Kitchen Hacks #3 Common Measurement Conversions Powdered Milk Reconstitution Use volume of water equivalent to desired milk volume. 1 Cup Milk= 3 Tbsp Powdered Milk= 45 mL 3/4 Cup Milk = 2.25 Tbsp Powdered Milk 2/3 Cup Milk = 2 Tbsp Powdered Milk= 30 mL 1/2 Cup Milk = 1.5 Tbsp Powdered Milk 1/3 Cup Milk = 1 Tbsp Powdered Milk= 15 mL 1/4 Cup Milk = 3/4 Tbsp Powdered Milk Measuring Spoon Conversions 1/2 tsp= 2.5 mL 1 tsp= 5 mL 1 + 1/2 tsp= 1/2 Tbsp= 7.5 mL 2 tsp= 10 mL 3 tsp= 1 Tbsp 6 tsp= 2 Tbsp= 1/8 c Liquid Measurement Conversions 1 fluid ounce= 2 Tbsp= 6 tsp 2 fluids ounces= 4 Tbsp= 1/4 cup 2+2/3 fluid ounces= 5 Tbsp + 1 tsp= 1/3 cup 4 fluid ounces= 8 Tbsp= 1/2 cup 6 fluid ounces= 3/4 cup 8 fluid ounces= 1 cup 16 fluid ounces= 2 cups= 1 pint 4 cups= 2 pints= 1 quart 4 quarts= 1 gallon Substitute dry for fresh spices 1:3 of dry:fresh 1 tsp dry= 1 Tbsp fresh 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

3 < Back Acute Care Surgery Clinical Guidelines EAST Practice Management Guidelines. Evidence-based guidelines developed and published by EAST. Covers EGS, ICU, trauma, and injury prevention. SurgicalCriticalCare.Net . Evidence-based guidelines from Orlando Regional Medical Center. Vanderbilt Trauma and Surgical Critical Care Practice Management Guidelines. Evidence-based guidelines developed by Vanderbilt. Covers trauma and surgical critical care topics. Evidence-Based Decisions in Surgery. This does require membership with the American College of Surgeons. General Medical Information UpToDate. The name says it all- evidence-based recommendations based on the most current literature. Subscription required. Previous Next