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7 < Back Training Courses Trauma Courses Advanced Trauma Life Support (ATLS). Systematic team-based management of trauma. Advanced Surgical Skills for Exposure in Trauma (ASSET). Cadaver dissection for vascular exposure. Advanced Trauma Operative Management (ATOM). Live tissue dissection for trauma exposures (pelvic hemorrhage, solid organ and hollow viscus injury management, retroperitoneal exposure, basic management of thoracic trauma). Basic Endovascular Skills for Trauma (BEST). Hands-on training in REBOA. Stop the Bleed. Training course for the public to learn how to control hemorrhage. Critical Care Courses Fundamental Critical Care Support (FCCS). Primer for non-intensivists on critically ill patients' initial management when critical care consultation is not immediately available. Emergency General Surgery Courses Emergency Surgery Course. Training course for non-trauma surgeons. Topics include abdominal sepsis, bowel obstruction, colorectal emergencies, cholecystitis, obstetric emergencies. Training Course Texts Advanced Trauma Life Support (ATLS) 10th Edition Student Course Manual. The newest edition of the manual. Fundamental principles of initial trauma evaluation, diagnosis, and management. Advanced Surgical Skills for Exposure in Trauma: Exposure Techniques When Time Matters (ASSET). Trauma exposures, particularly peripheral vascular access. Advanced Trauma Operative Management (ATOM). Operative techniques in trauma. Trauma: Code Red (Khan). 1st edition, 2019. Companion to the RCSEng Definitive Surgical Trauma Skills Course. Previous Next

< Back Ultrasound: Thoracic Exam Purpose: evaluate for etiology of respiratory failure- pleural fluid collections, pneumothorax, infiltrate, pulmonary edema. Probe Linear for visualization of superficial structures- for example, the pleural interface to evaluate for lung sliding Curvilinear or phased array for the remainder of the lung Findings A and B Lines A-lines- *normal finding*. Hyperechoic arcs parallel to the pleural line. These are seen at intervals that are the same as the interval from the skin to the pleural line. Absence of A lines= change in attenuation coefficient of the lung (edema, consolidation). B-lines- vertical hyperechoic lines, caused by fluid-filled intra-lobular or interlobular septa touching the visceral pleural surface. Examples: cardiogenic pulm edema, ALI, ARDS, pneumonia, ILD or pulm fibrosis, pulm contusion. Comet tail artifact- *normal finding*. Arise from the pleural line and only extend 2-4 cm deep before fading (unlike B lines). They mean that the pleura are in contact. Pleural sliding Shimmering of the hyperechoic pleura→ pleura are in contact. No sliding→ concerning for PTX. There are clinical conditions other than PTX that result in a lack of lung sliding: Effusion, inflammatory adhesions, (pneumonia, ALI), pleurodesis, interstitial or fibrotic lung disease, pleural disease, apnea, severe hyperinflation (asthma, COPD), artifact (subQ air). M mode- sliding→ seashore. No sliding→ barcode. Lung pulse - cardiac motion causes the two pleura to slide Lung point - the junction between the edge of the pneumothorax and the normal lung, where the pleural surfaces meet. One side is sliding and the other side isn’t. Consolidation Air bronchograms- air in small aerated patches of the consolidated lung, or the small bronchi. Dynamic- bubbles move in and out with each breath- no complete bronchial obstruction, more likely true consolidation vs atelectasis. Pneumonia- advanced consolidation (air is completely replaced with fluid)→ lung appear to have a liver-like echogenicity (hepatization) Diaphragm - evaluate diaphragm contraction and thickness. Effusions Spine sign- the presence of a large effusion allowing visualization of the spine. Normally the air in the lung prevents visualization of the spine above the level of the diaphragm, but sound waves can pass through the fluid. Plankton sign- floating debris in an effusion that swirl with pulm or cardiac motion→ blood/ fibrin suggestive of HTX/ exudate Jellyfish sign- consolidated or compressed lung is floating in the pleural fluid. Common Pathologies with their associated ultrasound findings PTX- no lung sliding, M-mode barcode sign, lung point sign, A-lines from intact parietal pleura Pulmonary edema- B lines, normal lung sliding, +/- effusions ARDS- B lines, normal lung sliding References Lung Ultrasound Made Easy: Step-By-Step Guide Lee FC. Lung ultrasound-a primary survey of the acutely dyspneic patient. J Intensive Care. 2016 Aug 31;4(1):57. Previous Next

< Back Chunky Tomato Bisque Ingredients 6 celery ribs, chopped 1 large onion, chopped 1 medium sweet red pepper, chopped 1/4 cup butter, cubed 3 cans (14.5 oz each) diced tomatoes, undrained 1 tablespoon tomato paste 3/4 cup loosely packed basil leaves, coarsely chopped 3 teaspoons sugar 2 teaspoons salt 1/2 teaspoon pepper 1-1/2 cups heavy whipping cream Instructions 1. In a large saucepan, sauté the celery, onion and red pepper in butter for 5-6 minutes or until tender. Add tomatoes and tomato paste. Bring to a boil. Reduce heat; cover and simmer for 40 minutes. 2. Remove from the heat. Stir in the basil, sugar, salt and pepper; cool slightly. 3. Transfer half of the soup mixture to a blender. While processing, gradually add cream; process until pureed. Return to the pan; heat through (do not boil). The vegetables sautéing Previous After blending Dinner is served! Next

< Back Electrolytes...pending Electrolyte Management Previous Next

< Back Stabbed in the Right Thigh A 42-year-old male is brought to the Emergency Department as a Level 1 trauma activation for a stab wound to the right thigh. He was hypotensive before arrival, with SBP in the 70s-80s. Estimated blood loss of 500 mL on the scene. On arrival, the patient is awake and argumentative. His blood pressure is 90 systolic. On a rapid secondary survey, there is no evidence of any other wounds. There is a tourniquet in place to right upper thigh. When the tourniquet is released, there is arterial bleeding from the wound and there is no palpable distal pulse. What do you need to do before leaving the trauma bay? Replace tourniquet. Call OR to have vascular instrument set available, as well as massive transfusion, cell saver, etc. Type and cross for blood transfusion. After ensuring a type and cross, we proceeded to the operating room. How do you want to prep and drape the patient? Any instructions for anesthesia? Wide prep and drape to ensure adequate access for proximal and distal control- this includes prepping the lower abdomen for possible iliac exposure. Also, need to prep contralateral lower extremity for potential saphenous vein harvest. Ultrasound localization of the saphenous prior to prepping can allow identification of the larger vein. Anesthesia will need to monitor hemodynamics and volume status and be prepared for volume resuscitation with blood. In addition, they will have to be vigilant for the repercussion syndrome, the metabolic disturbance following the re-establishment of arterial flow (washout of toxins following ischemia). We placed a pneumatic tourniquet on the patient's upper thigh. We prepped and draped from the umbilicus to the knees, and also prepped and draped the contralateral thigh to have access in case a saphenous vein harvest was required for repair. We made an incision directly over the wound and dissected down to the artery. There was a single wound in the anterior surface of the distal superficial femoral artery. Proximal and distal control was obtained after circumferentially dissecting and placing vessel loops. The artery was divided and spatulated. It was repaired with an end to end tension-free anastomosis. Following arterial repair, we performed a lower extremity fasciotomy. Management of Penetrating Arterial Trauma WTA Algorithm Diagnostic Workup Hard signs- pulsatile bleeding, thrill, bruit, expanding hematoma, pulse deficit, cold pale limb. These patients require operative intervention. A few exceptions can benefit from preoperative imaging to document the presence and location of associated arterial injuries: wounds in the thoracic inlet, shotgun wounds in the extremities, and segmental fractures or fractures at different levels of an extremity. Soft signs- history of pulsatile bleeding, wound near an artery, non-expanding hematoma, neuro deficit, weak pulse, proximity injury. These patients need further workup to evaluate for the presence of arterial injury. An ankle-brachial index should be performed, and if ≤0.9, CT angiography is indicated. If ABI >0.9- no further w/u needed. ABI <0.9- CTA. Principles of arterial repair 1. Plan incision to facilitate proximal and distal control. 2. Ensure adequate back bleeding. Fogarty to remove distal thrombus. 3. Tension-free anastomosis. Adequate lumen. Clean margins. Don't create more damage to the vessel. 3. Consider risk/ benefit of heparinization. Systemic dose: 70-100 units/kg IV. Regional dose: 50U/ml x50 mL. 4. Completion angiogram to document repair. There are various techniques for creating an anastomosis, but the basic principles must be maintained. Recently, I was taught a useful technique [Dr. Feliciano, AAST 2020 Virtual Conference] that prevents tension at one point along the anastomosis. A parachute technique, starting with loosely approximated sutures on the back wall, followed by parachuting the two ends close to continue the suture on the anterior surface of the artery. Indications for fasciotomy include prolonged limb ischemia (>6 hours), combined arterial and venous injuries. 1. Feliciano DV. Evaluation and Management of Peripheral Vascular Injury. Part 1. Western Trauma Association/Critical Decisions in Trauma. J Trauma. 2011;70(6):1551-1555. 2. Feliciano DV. Pitfalls in the management of peripheral vascular injuries . Trauma Surg Acute Care Open. 2017;2:1–8. Parachute Technique [Feliciano] WTA Algorithm for Peripheral Vascular Trauma 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 Vent Mgmt #4: All Together Choosing a mode Controlled- patients who aren't generating breaths. PC, VC. Most common mode at initiation of MV. SIMV- patient generating some breaths, but still needs significant mechanical support. Spontaneous- not frequently used at initiation, but can be used for patients with airway obstruction and preserved lung function. How to set initial parameters TV (6-8 mL/ kg predicted body weight) [lung protective ventilation] RR 10-14 FiO2 often start at 100%, but quickly weaned unless severely hypoxic Inspiratory:expiratory ratio typically 1:2 Flow- typically set @ 60L/min, can increase if the patient is in distress or has a high minute ventilation How to adjust parameters based on arterial blood gas results Low PaO2 (low arterial oxygen content)- increase FiO2, increase mean airway pressure Markedly elevated PaO2 (hyperoxia)- decrease FiO2 Low PaCO2 (low arterial carbon dioxide concentration)- decrease TV or RR High PaCO2 (high arterial carbon dioxide concentration)- increase TV or RR *For more details, check out these resources: Lectures: Critical Care: Respiratory Failure Lectures: Critical Care: Vents Other principles of mechanical ventilation VAP bundle- elevated head of bed, oral care Daily awakening and spontaneous breathing trials 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

< Back Fever...pending Evaluation of Fever Previous Next

3 General Surgery Lectures General Surgery .pdf Download PDF • 152.12MB Anorectal .pdf Download PDF • 1.55MB CT Scan and X-ray .pdf Download PDF • 564KB Vascular .pdf Download PDF • 13.57MB Suture .pdf Download PDF • 4.94MB

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

How not to lose everything < Back Organizational Hacks How not to lose everything All my life, I've been forgetful and easily distractible. I joke that I'd lose my head if it wasn't attached. This challenge is part of my ADHD, and I can't overcome it with sheer willpower. The list of things that I've lost over the years is staggering- homework (oh so much homework…it was usually stuffed somewhere in my locker), clothing, books, charging cables, water bottles, earrings (what am I supposed to do with the remaining single earrings?) and a white polar bear stuffed animal (he was left in a hotel room on a road trip as a child). I'm looking forward to learning where all my things went when I die and go to heaven. So if this can’t be overcome with sheer willpower, how can you adapt? Check out these techniques or tools to see if you find something that would be useful for yourself. Information * Create a tool for yourself for storing the data you need to be able to access reliably. This website is full of high-yield medical information that is rapidly accessible, but a website is a labor-intensive option. You don’t have to invest time and money into a website. Here are some other options (check out this post for more details ): - Invest in a planner . Electronic options that sync are useful because they minimize the need to re-write things in multiple places. Another option that I prefer is one notebook that keeps all my events in one place, along with my collection of lists and reminders. - Write everything down. My planner is my note repository. The Apple Notes application is also useful because it can sync across multiple Apple devices. At home or work, dry-erase poster paper can be used to take notes, keep track of schedules and provide reminders for long-term tasks and due dates. - Trello is a user-friendly free application with multiple functions, including the creation of lists, storage of documents, and the ability to share notes or documents among team members/ family members. Items * Magnet strips . Using magnetic sheets the size of business cards, cut pieces and strips to put on various items and stick them to the fridge or other magnetic surface of your choice. For example, if you use dry-erase poster paper on the refrigerator, thin strips of magnet can be cut to fit along the length of several dry eraser markers, so they're always on hand when you have something to jot on the whiteboard * Keys on a hook by the front door. 3M hooks work well, but the hook design isn’t as important as placement, ideally not in direct sight of the door. You can also hang your work ID badge or any other small items you need when you leave the house. * Keep track of all your cords with these tie wraps . Inexpensive and sturdy. I didn’t think there was any way I’d use 50- I figured maybe a couple, just for a handful of my charging cables that always end up in a jumble. But trust me, you'll find plenty of uses for them! Finances and Important Documents * Save receipts for anything valuable. If it was purchased online, download the digital receipt. Use the "Create PDF" function to combine receipts. For paper receipts, an envelope in a drawer is a simple option. Every so often, review the receipts, and if there is anything you don't need anymore, toss it. * Paper shredder . Anything with personal information should be destroyed before being thrown away. This is technically not about avoiding losing something, but it’s an important task so it is included here. * Taxes. Instead of waiting until tax season, keep track of key documents and expenses throughout the year. A running spreadsheet of business expenses, donations, etc, can avoid the frantic search in March. * Metal rack of hanging file folders. Each folder has a different label, including taxes (donation receipts, investment statements, etc), moves (signed leases, welcome packet with key information, etc), and business (bank paperwork, original EIN and registration forms, deposited checks). Previous Next