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< 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

Stereotype of a Surgeon Heartless with a God Complex < Back Stereotype of a Surgeon Abrasive, intimidating, self-confident, egotistic, stubborn, arrogant, difficult to work with, aggressive, competitive, and domineering, technically masterful, astute, energetic, and precise.(1) These are just a few of the adjectives that have been used to describe surgeons. The top Google autocompletes for the phrase "why are surgeons…” include arrogant, rough, rude, important, jerks, mean, cold, weird. There is a balancing act between the need to demonstrate confidence while maintaining our humanity and our humility. We wield sharp instruments, and we ask our patients to trust us to fix them while they lay naked and exposed, anesthetized, and vulnerable. So how do we reconcile these seemingly opposing characteristics? How do we show strength, leadership, and confidence in our decision-making and skills and also develop a rapport with patients and families? How do we show our patients that we will be with them to celebrate their recovery and stand by them in the face of complications and setbacks in their recovery? Effective communication is key to relationship building. In general, surgeons are not known for their stereotype that surgeons don't have the best bedside manner. "As a group, surgeons are not well known for their bedside manner."(2) We (usually) operate on completely unresponsive patients, so the stereotype that we don’t like talking to patients is not illogical. This stereotype extends to anesthesiologists. While this is a satirical representation, there is a kernel of truth in the idea that most don’t go into specialties that frequent the OR to spend MORE time talking to patients. "While poor manners aren't commonly accepted in most professional circles, representations of surgeons in popular culture often link technical prowess with rude behavior, and some surgeons have even argued that insensitivity can be helpful in such an emotionally strenuous profession."(2) I probably spend more time talking to patients and their families than the typical surgeon. I find these personal interactions to be truly remarkable. During my training, I developed my style for communication. When I share information with a patient and their family, I treat them as if it were my family member. Based on my perception of their interest in detail and my direct explanation that I will share as much or as little as they like, I tailor my interaction with each new encounter. I believe in full disclosure, including admitting when I don’t have the answers. My training has given me the confidence to admit when I need more information or plan to consult with a colleague. Some might see my willingness to admit imperfections as a sign of weakness. While I didn’t develop my practice regarding disclosure with the express intention of avoiding legal consequences, poor communication and lack of empathy are commonly cited in malpractice suits.(3) So besides the intrinsic benefit of developing respectful interactions with patients, the extrinsic factor of avoiding the courtroom is powerful. A study published in 2019 found that surgeons are regarded as high in warmth and competence, relative to other non-medical occupational groups,(4) in contrast with the stereotype that we lack social skills. The study also noted that female surgeons received higher warmth ratings than male surgeons, while male surgeons received higher competence ratings than female surgeons. It is not an easy task, but building trust with our patients requires us to instill confidence while maintaining our humanity. 1. Logghe HJ. History of Medicine: The Evolving Surgeon Image. AMA J Ethics. 2018;20(5):492-500. 2. Neilson S. When Surgeons Are Abrasive To Co-Workers, Patients' Health May Suffer. 2019 Jun. NPR. 3. Huntington B. Communication gaffes: a root cause of malpractice claims. BUMC Proceeding. 2003;16:157–161. 4. Ashton-James CE. Stereotypes about surgeon warmth and competence: The role of surgeon gender. PLoS ONE 14(2): e0211890. Previous Next

< Back Free Fluid in the Abdomen A 62-year-old male presents following a motor vehicle collision in which he was an unrestrained driver. He was intubated in the trauma bay for decreased mental status. A focused assessment with sonography for trauma (FAST) was performed, which did not reveal intra-abdominal fluid. Computed tomography (CT) of the head demonstrated minimal intra-cranial injury. CT of the abdomen and pelvis (see below) revealed decreased blood supply to the left kidney, small irregularity of the splenic contour, and a moderate amount of free fluid in the abdomen and pelvis. Hounsfield units are consistent with simple fluid. CT of the abdomen and pelvis https://video.wixstatic.com/video/3b6ff6_b03419943e9941d281c3d8f0b800e37f/480p/mp4/file.mp4 What is the differential diagnosis for the free fluid in the abdomen? Free fluid due to trauma can be urine, enteric contents (bowel injury with spillage of succus) or blood. It is possible to have fluid present prior to the trauma, such as ascites from chronic liver disease. In this case, the free fluid in the abdomen had characteristics of “simple fluid,” based on Hounsfield units, suggesting that the fluid was not blood. In females, free fluid in the pelvis can be normal (physiologic fluid). However, free fluid is NOT normal in a male, and it's concerning for hollow viscus injury. What are the possible causes of decreased blood flow to the kidney? The renal artery can be injured in blunt trauma. Blunt injury can disrupt the layers of the artery wall, leading to thrombosis and decreased blood flow beyond the injury. He was admitted to the intensive care unit. A foley catheter was placed and demonstrated pink-tinged urine [NOT frank gross blood/ clots]. What are the possible causes of blood-tinged urine? Bloody urine indicates a traumatic injury to the genitourinary tract, anywhere from the kidneys down to the urethra. A CT cystogram was performed, which did not reveal any extravasation of contrast from the bladder. CT Cystogram https://video.wixstatic.com/video/3b6ff6_119074429b224cc98677d4f101fef666/480p/mp4/file.mp4 Next steps? Based on an unreliable physical exam and a normal CT cystogram, it is necessary to rule out bowel injury. The patient was hemodynamically stable and had normal laboratory values. He remained with a decreased mental status, and therefore serial abdominal exams were not a viable management plan. The patient was taken to the operating room and underwent diagnostic laparoscopy. His small bowel, colon, and mesentery were examined in there entirety and found to be completely normal. There was a small amount of clear thin fluid in the pelvis, but there was no evidence of bile staining or bleeding. After completing the evaluation of the gastrointestinal tract, we repositioned the patient in Trendelenburg. The pelvis was inspected, and it was quickly apparent that the patient in fact had a large defect in the dome of the bladder. We elected to proceed with a low midline laparotomy. The bladder was easily mobilized, and the extent of the defect was defined. The edges were grasped, and the defect was closed in two layers with absorbable suture. Postoperatively, we reviewed the preoperative CT cystogram. In retrospect, there was a suggestion of bladder irregularity. We reviewed the CT cystogram with the radiologist and there was no evidence of contrast extravasation. However, the bladder does not appear to have been completely distended with contrast. It is very atypical that a large bladder wall defect was not associated with contrast extravasation, and this highlights the importance and ensuring complete filling of the bladder with contrast. Evaluation and Management of Bladder Injuries Bladder injuries can occur from blunt or penetrating trauma. For example, bladder injuries can occur when blunt force is exerted on a full bladder or in the setting of a pelvis fracture. Diagnosis Gross hematuria is seen in most patients with bladder injuries. Cystography, either using plain x-ray or CT, is the diagnostic test of choice. Management The management of bladder injuries is based on location. Intra-peritoneal injuries require operative management. This is done in two or three layers with absorbable suture. A decompressive foley catheter is left following repair. Extra-peritoneal injuries can typically be managed non-operatively with a foley catheter for 10-14 days. Exceptions include large bony segments protruding into the bladder wall, associated rectal or vaginal injuries, bladder neck injuries, or an associated pelvic fracture undergoing operative intervention to prevent hardware contamination. Current guidelines recommend a cystogram before foley removal, except for the most uncomplicated injuries. Yeung LL et al. Management of blunt force bladder injuries: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2019;86(2):326-336. 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

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 Vent Mgmt #5: Weaning When is the patient ready to start ventilator weaning? Resolution of pathology resulting in the need for mechanical ventilation Able to assess mental status (ie can the patient follow commands) Hemodynamics and respiratory physiology is optimized (ie ABG normalized or returned to patients baseline, and normalization or stabilization of cardiac function) Minimal ventilator settings (FiO2 21%, PEEP 5) NOTE: Even if there is no immediate plan to extubate, sedation holiday and spontaneous breathing trials should still be performed [unless there are specific contraindications] Spontaneous breathing trial Spontaneous mode of ventilation (such as pressure support or CPAP) with 5-8 cm H2O support during inspiration (basically overcoming the force required to breath through the small diameter of the ETT) Failing SBT Hemodynamic instability (hypotension or hypertension, tachycardia or bradycardia) Agitation Respiratory instability (hypoxia, inadequate tidal volume, tachypnea or decreased respiratory rate) Extubation parameters- how do we know if the patient is ready to be liberated from the ventilator? Able to generate adequate minute ventilation Rapid shallow breathing index (RSBI)- RR/ TV. High respiratory rate (rapid) and low tidal volume (shallow) are more suggestive that a patient isn't appropriate for extubation. Value <105 suggests the patient will successfully extubate. This is also known as the Tobin index.[1] Negative inspiratory force (NIF)- the patient's ability to generate negative pressure with inhalation. Cuff leak- ability to move air around the endotracheal tube. Not mandatory to evaluate for cuff leak prior to extubate EXCEPT for patients is at high risk for airway edema (traumatic intubation, intubated >6 days, large ETT, female, reintubation after unplanned extubation). Reasons for failed ventilator weaning Prolonged hospitalization and associated weakness Hypophosphatemia Primary process requiring mechanical ventilation is unresolved Passed SBT...but failed ventilator liberation? Excess secretions/ inability to cough Cardiac instability related to physiological changes with loss of positive pressure (specifically decrease in intra-thoracic pressure leading to decreased cardiac output) Tobin Index. Yang KL, Tobin MJ. A Prospective Study of Indexes Predicting the Outcome of Trials of Weaning from Mechanical Ventilation. N Engl J Med. 1991 May 23;324(21):1445-50. 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

< Back Getting Involved Getting involved in your training program and hospital is crucial for your professional development and growth. Here are some tips to help you get started. - Be open to opportunities to get involved early and embrace small projects. Even if a project seems insignificant, it can lead to bigger opportunities. Don't hesitate to accept requests to help write a paper, design a research protocol, or participate in a committee. These small projects can open doors for more significant roles and responsibilities in the future. - Be proactive and take the initiative to get involved. Talk to your mentors and program directors about your interest in participating in projects or committees. Ask for guidance on how to get involved, and don't be afraid to express your interest in specific areas. - Get involved in research. You don’t have to have a strong research background to contribute to ongoing projects. If you have specific research interests, seek the advice of someone with a similar interest and collaborate with them. Different faculty members will have their individual strengths and passions, which are frequently apparent after you interact with them. If you partner up with someone who has a similar interest, they will be able to guide you and lend their support to your project. Training programs frequently have requirements for research and have a framework for supporting involvement in ongoing projects. Research requirements are often a part of training programs, so take advantage of the support and resources available to you. Also, keep in mind that there may be ongoing research projects at your hospital that you can contribute to. - Attend department and hospital level conferences. Grand rounds, morbidity and mortality (M&M) and case conferences are invaluable learning opportunities. Conferences that review complications or deaths are invaluable learning opportunities. They are also a good platform for developing performance improvement projects. Many patient incidents are multifactorial, and there are frequently systems issues that can be addressed to minimize repeat events. - Join committees. Committees are a great way to learn about the inner workings of the hospital and contribute to important decision-making processes. They also provide a venue to meet colleagues in other departments and gain valuable networking experience. - Talk to people. Reach out to your mentors, program directors, and research staff about other opportunities that may be available. They can often provide valuable insight and connections that can lead to new opportunities and projects. After you have explored the opportunities to get involved in your program and hospital, it’s time to widen your professional network. Expanding beyond your hospital will help you stay current with industry trends, discover new opportunities, and establish relationships with colleagues and mentors. One way to do this is by participating in surgical organizations at the national level. Here are some examples: - American College of Surgeons (ACS). The ACS offers membership and participation opportunities starting in medical school. As a member, you can take advantage of educational programs, networking events, and leadership development opportunities. Fellowship in the ACS (FACS) requires board certification, and it is a prestigious recognition that can enhance your professional reputation. - American Association for the Surgery of Trauma (AAST). AAST is the premier national organization for the field of acute care surgery (trauma, surgical critical care and emergency general surgery). There are numerous opportunities for involvement in research and professional development. Membership requires FACS status. However, the organization recently added an associate membership category, which offers younger surgeons an opportunity to participate in the AAST's activities and programs. - The Eastern Association for the Surgery of Trauma (EAST). EAST provides leadership and development opportunities for young surgeons who are actively involved in the care of injured patients. The organization offers ample opportunities to get involved in committees, research projects, mentorship, and leadership roles. This is far from an exhaustive list, but it is a good starting point for young surgeons to explore how they want to develop their network. During my Acute Care Surgery fellowship, I was able to get involved in various research projects and initiatives that allowed me to further develop my expertise and knowledge in the field. At the start of my fellowship, I developed a research protocol that evaluated the impact of legislation on the opiate epidemic. This project allowed me to delve into a critical issue facing the healthcare industry and explore potential solutions to mitigate the epidemic's impact. Shortly after, I attended a department committee that updated our clinical practice guidelines. As we discussed some recent patients with rib fractures, I saw the importance of updating our thoracic trauma management guidelines. I partnered with one of the faculty who had a particular focus on rib fracture management and we worked to optimize our protocol for caring for these patients. This led to multiple opportunities, including an IRB protocol and two manuscript submissions on operative rib fixation. I also had the opportunity to co-author a book chapter on Intensive Care Unit (ICU) management of blunt chest trauma and a manuscript on the use of opiates in chest trauma. During a meeting with one of the research directors in our department, I was able to learn about opportunities to get involved in ongoing projects. This led to me joining a group working on coagulopathy in traumatic brain injury. Through this project, I was able to contribute to a literature review submission and co-author a research manuscript submission. I was also able to present our findings at a national conference. My program director was a strong supporter of and actively shared news about opportunities that could further my career development. One of these opportunities included writing an essay that allowed me to publish and present at a conference. After reading my essay, a critical care physician reached out to connect and invited me to participate in testing a tool for resuscitation in austere environments. This was a unique opportunity that allowed me to apply my knowledge and skills in a new and challenging setting. Overall, my Acute Care Surgery fellowship allowed me to explore different avenues in research and develop expertise in areas that I am passionate about. It also enabled me to collaborate with other experts in the field, broaden my network, and gain invaluable experiences that served me well in my future career endeavors. 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 Anorectal Disease Anorectal pain is an incredibly common condition . Thanks to our low-fiber Western diet and often inadequate hydration, constipation is a frequent occurrence. People also often spend long periods on the toilet. We used to read books, but now many play games or text on their smartphone. Constipation and prolonged sitting on the toilet can lead to several different problems. While discussing these symptoms can be awkard or uncomfortable, please talk to your doctor if your symptoms don't go away on their own. So what is anorectal pain? Although "butt pain" may be a common complaint, I want to be clear with my explanations. In reality, “butt” more accurately refers to the gluteal region, which is also known colloquially as derriere, buttock, backside, or fanny. It may be simplest to describe the butt as the area that rests on the surface of a chair when you sit. Anorectal refers to a more specific location, the anus and rectum, where stool passes through when you have a bowel movement. Please see the anatomically correct depiction below. What are the common causes of anorectal pain? Fissures Hemorrhoids Pruritis Ani Abscesses Less common- pelvic floor dysfunction, cancer Anatomy of the anus and rectum Two sphincter complexes encircle the rectal vault. The internal sphincter provides 85% of the resting tone. It is under involuntary control- this is how your body controls when you have a bowel movement. The external sphincter provides 15% of resting tone- it is under voluntary control, which means this is how you consciously control holding in a bowel movement. The internal hemorrhoids are veins that line the inside of the rectum, while the external hemorrhoid plexus is on the anal verge. These means that hemorrhoids are a NORMAL part of anatomy! They fill with blood to aid in incontinence, helping you control when you have a bowel movement. Anything that increases pressure in the abdomen, including prolonged straining, coughing, pregnancy, and enlarged prostate requiring straining to urinate, can lead to abnormally large venous plexuses, which are what most people know as hemorrhoids. See “Hemorrhoids” below for more details. Glands line the inside of the rectum and help lubricate stool. When the glands become obstructed, they can lead to abscesses. What are the common symptoms of anorectal disease? Pain Bleeding- either blood dripping in the toilet, blood on the toilet paper with wiping, and blood mixed with or on the stool's surface. Mucus drainage (constant moisture), which can cause challenges with perianal hygiene Pruritis (itching) Palpable mass Constipation/ diarrhea, incomplete voiding What causes anorectal disease? Prolonged straining or prolonged time sitting on the toilet, often due to constipation (hemorrhoids) Constipation and passing a hard stool can lead to tears in the skin (fissure) Underlying gastrointestinal disease (inflammatory bowel disease, etc.) How do I prevent anorectal disease? The goal is to improve bowel habits and minimize constipation. High fiber diet. Most Americans have a low-fiber diet, consuming way less than the recommended 20-35 grams of fiber per day. Fiber can come from dietary intake (the foods you eat) as well as supplements. Take the time to read labels. The foods we commonly think of as “high-fiber,” including lettuce, are not as fiber-rich as we think. A word of warning If you quickly add a significant amount of fiber to your diet, this can lead to gastrointestinal distress (gas, diarrhea, cramping, etc.). Add fiber slowly until you reach your goal! Stay hydrated! Fiber without adequate hydration will create hard stools (rabbit pellets), making constipation worse. The recommendation is a minimize of 64 ounces of water per day. Plain water is best, but flavoring with Crystal Light, lemon, or lime can make it more palatable. Listen to your body regarding bowel movements. Hold it until socially acceptable, but don’t hold for longer than necessary. But just as important, don’t force a bowel movement if you don’t feel the urge. Some people may be trained to try to have a bowel movement before leaving for work- if this works for you, that’s fine. But don’t let the clock dictate when you have to use the bathroom. Minimize the amount of time sitting on a toilet. Prolonged sitting increases pressure, which predisposes to pathology. If you are still having challenges, consider investing in a device to facilitate improving your posture. We are accustomed to using toilets…unfortunately, sitting creates an angle that makes it difficult to have a bowel movement. Squatting, with knees elevated closer to the chest, creates a straighter path leading to more optimal conditions to have a bowel movement. Consider a squatty potty! Specific Anorectal Pathology Hemorrhoids Anal Fissures Pruritis Ani Patient Info- Fiber Guide .pdf Download PDF • 68KB Patient Info- Hemorrhoids .pdf Download PDF • 58KB Patient Info- Anal Fissure .pdf Download PDF • 59KB Patient Info- Pruritis Ani .pdf Download PDF • 58KB Patient Info- Constipation .pdf Download PDF • 54KB Previous Next

< Back Pneumonia...pending Pneumonia Previous Next

9 Black Swan The Impact of the Highly Improbable - Silent evidence- you can’t determine causality just by studying the successes. You don’t know the traits of the failures- they could be the same as the successes. Failed writers aren't necessarily bad writers. - The absence of evidence (no evidence of disease) doesn’t mean evidence of absence. - Recognize the unknown unknowns. - Mediocristan (finite limits- weight, height, etc.). Extremistan (boundless- income, book sales, retweets). - The turkey, which is fed every day until thanksgiving, doesn't realize he's getting closer to death. - When a black swan occurs, people rationalize in hindsight and state that it was inevitable. - Series of events preceding a particular situation doesn’t imply causality. We give narratives to make sense of events. - Humans are the victims of an asymmetry in the perception of random events. We attribute our successes to our skills, and our failures to external circumstances outside our control, mainly, to randomness. There is something in us designed to protect our self-esteem. - The law of iterative expectations. If I expect to expect something at some date in the future, I already expect that something now. Stone Age historical thinker is called to write about the events of the era. If he predicts the wheel, then the wheel already exists as a concept. - Different conclusions can be drawn from the same data. Every day you’re alive...you could be closer to death or immortality. Previous Next