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 Gunshot Wound to the Leg A 26-year-old male soldier sustained a gunshot wound to the right medial thigh. He had a compressive dressing that was placed prehospital. He arrived at the hospital and underwent a rapid primary and secondary survey. Initial X-ray Evaluation? Radiologic imaging. Evaluation for extremity vascular injury. He had active bleeding from the wounds. After plain films and initial stabilization, the patient underwent operative exploration of the vascular structures of his right lower extremity. His right femoral artery was intact. His right femoral vein was transected and there was a long segment of destroyed vein, which was treated with ligation. He underwent right lower extremity fasciotomy. This was followed by femur fixation with the placement of an external fixator. Intraoperative Image Postoperative Image Management of Combined Arterial and Orthopedic Injury EAST Guidelines In this scenario, the priority is restoring distal arterial blood flow to minimize ischemia time. If there is an associated unstable fracture, blood flow can be re-established with a temporary intravascular shunt, followed by rigid fixation of the bony injury. If the arterial injury is definitively repaired, it can become disrupted with the manipulation required for rigid fixation. If the associated fracture is stable, the arterial injury can be repaired before addressing the fracture. Previous Next

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

< 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

Meal Prep: Eating with Intention < Back Kitchen Hacks #1 Meal Prep: Eating with Intention Want to stop eating cereal or takeout for dinner? Want healthy food options in the house? Whether you have a big family or you’re cooking for one, you CAN be more purposeful about your eating habits. Cooking healthy delicious meals while maintaining variety at meal time and keeping your kitchen stocked so that you’re able to cook without having to make multiple trips to the store doesn’t have to be an intimidating endeavor. Let’s walk through the key components of a successful cooking plan. * Create a collection of recipes . Some people might not routinely rely on recipes when cooking- if that’s you, feel free to skip over this. However, for the rest of us, recipes serve as the basis for meal prep. Your collection can be as simple or complex as you want. Recipe cards in a box or book, pages ripped out of magazines, cookbooks with bookmarks, links to recipes online, a basic phone app or even just a simple word document- whatever works best for you. After you decide on how to collect your recipes, the next step is making recipes easy to find. ** Organizing- Start with a few broad categories, such as breakfast, side dishes, sandwiches, main course and dessert. Once you are familiar with how you use your recipe collection, feel free to create more specific categories. For example, my categories include apps and side (sub-category: vegetables), bread (sub-category: breadmaker), breakfast, dessert (sub-categories: brownies and bars, cakes, candy, cookies, cupcakes, ice cream and pies), dinner (sub-categories: chicken, crockpot and fish), dips and sauces, new recipes, pasta, pizza, salad and finally, sandwiches and burgers. * Create a collection of meals. You probably have a few combinations that you routinely prepare and serve. For example, meatloaf, mashed potatoes, and green beans. Not every food needs a recipe, and you might even do some meals from memory. But creating a list of meals can help remind you of dishes you haven't had in a while and gives you more options to choose from when you’re in a rut. * Create a list of items in your pantry (and fridge/ freezer)- specifying quantity is important. You don’t have to include every item, but keeping track of commonly used items can help avoid situations such as three extra bags of white sugar or running out of key spices. * Create a meal schedule. Just like everything else, this can be as simple or detailed as you would like. Whether you do a weekly meal prep session or plan meals a day or two at a time, a schedule can help you remember to set aside or purchase the necessary ingredients ahead of time. A schedule can also help when projecting leftovers- like what meals are a good setup for packing a lunch the next day. * Create a grocery list. At a minimum, you should jot down what you need before leaving the house. But there are several ways to optimize your preparation for the grocery store. Making the list at home is key, because you can check what you have in your pantry/ fridge. ** Develop a list of commonly purchased items - this will make it easier to add things to your list before you head to the store. ** Keep a list near the refrigerator or pantry- this can be a simple notepad, a white board or whatever else suits you. When you are in the kitchen and notice that you are running low on something you normally have on hand, just jot it down on the list. Then on shopping day, it’s easy to keep track of staple items. ** Using your meal schedule/ recipes, you can gather the ingredients that aren’t in your collection of staple items. This is often fresh fruit/ produce or dairy/ meats. ** If you find yourself at the grocery store on the way home from work (or anytime you haven’t had a chance to make a list), you can pull together a meal by selecting from your recipes or meals and then sorting through your pantry list to determine what ingredients are missing. * I recommend downloading the Paprika application (iTunes application , $4.99). It is an all-purpose tool for collecting/ sorting recipes, creating menus, keeping track of ingredients in your pantry/ refrigerator/ freezer and making a grocery list. You can add recipes from almost any website and can also manually add personal recipes (and even add a picture of your own creations!). You can create a menu schedule and grocery list directly from recipes. Keeping everything in one place avoids the need to refer to different resources (recipe book, list on the refrigerator, electronic version of a pantry list). * Here are two of my favorite websites for recipes. ** Cooking Light Free access to countless delicious healthy recipes! ** How Sweet Eats Started following this years ago when I stumbled on some of the recipes on Pinterest. Love the name- we are both fans of James Taylor! Previous Next

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

Give me that thing that does the thing… Kelly Snap Mosquito < Back Give me that thing that does the thing… I don’t remember the names of all the instruments in the surgical tray. I swear they have a unique name for each size of the same instrument. Hemostats- crile, snap, stat, mosquito, tonsil, Kelly, Rochester Pean. There is a laundry list of pickups of different shapes with different teeth. And then throw in the culture of different hospitals and specialties. When you place a Bookwalter and you want the short wide curved retractor…do you call it a bladder blade or a curved body wall? And the straight one…is that a Rich or a body wall? In case you’re wondering, the curved retractor is called a Balfour and the straight retractor is called a Kelly. When you’re doing a laparoscopic cholecystectomy, do you ever ask for a wavy grasper or do you call it a prestige? Or something else altogether? As I resident and attending, I used a wavy grasper . Check out the picture. Doesn’t it look like…a wavy? When I was in fellowship, the same instrument was called a prestige. Sounds unnecessarily boastful to me, but whatever. After 9 years using a wavy, it was hard to break the habit and call it a prestige. Thankfully, the scrubs knew what I wanted. I found out it's actually called a Prestige Style Atraumatic Wavy Grasper , so it turns out, we are both right. But that would take way too long to say each time you want to grasp the infundibulum. As we move through training, we develop routines, including our favorite instruments to use during different steps of the operation. When surgeons and scrub techs spend time together during cases, they frequently develop a rhythm, a shorthand. A good scrub tech knows what you want before you even ask. I have had the fortunate of developing several relationships like this. My favorite scrub tech was Kelly. She was a fantastic tech, but also a fantastic person. And the joke of asking for Kelly Kelly never got old. After years of working together, she understood my style and my technique, and always had my next instrument ready. To be honest, it didn’t take years. She knew what I wanted, even if I asked for the wrong thing. She was an invaluable asset to the team, and I miss working in the OR with her. As I mentioned, I don’t remember the names of all the instruments in the surgical tray. A good scrub tech gives you what you want, not what you ask for. While operating, I often extend my hand toward my scrub tech, and as I’m trying to come up with the right name, I start to make gestures with my fingers. Fingers posed like holding a pencil signals scalpel. Thumb and index finger pinched together is my gesture for pickups. Index and middle finger in an open/close motion indicate scissors. Curved fingers, like holding a cup, means I want a retractor. And I request a needle driver by holding the scalpel pose and moving my wrist through a suturing motion. There have been many innovations brought about by the COVID pandemic, and I predict that business will never be conducted the same as before this era. The protective gear worn to prevent viral transmission negatively impacts team communication. This was one of the summary findings of a survey of surgeons, recently published in the World Journal of Surgery.(1) The impact on speech discrimination has been quantified in an experiment with a simulated noisy background.(2) Google “communication impediment COVID protective equipment” and you will encounter many publications regarding the unintended consequences of interventions designed to keep health care personnel safer. Before the pandemic, we already operated wearing masks, which eliminates some of the visual cues of communication. But novel respirators can add several hindrances, including restricting normal jaw movement and muffling the spoken word. The use of the PAPR (powered air-purifying respirator) added a whole new dimension- noise from the fan and battery adds a remarkable hurdle when the surgical team is trying to communicate with other members of the operating team. Admittedly my system is imperfect, and I think a universal sign language for the operating room is a brilliant concept. A proposed system was recently published in the British Journal of Surgery.(3) Signals were developed to request a scalpel, various retractors, forceps, needle drivers, and gauze. This concept is logical, although admittedly, I have become increasingly reticent to accept any innovation just because it appears simple and absent of downsides. Consider the intubation boxes that were developed to prevent aerosol dissemination early in the pandemic. The concept was rational- solid barrier to isolate the patient, great idea! But during simulation, there were multiple hurdles- largely, it makes difficult intubation more challenging, which potentially defeats the purpose by increasing maneuvers and personnel and time to successful intubation. To quote one review: “Well-designed simulations…should always be used to test medical innovations before implementation... “Face validity” alone should not be the basis of innovation adoption.”(4) Is a new language necessary? Do we really need a system to talk to the tech, who is standing closer to us than anyone else in the room, and probably already knows what we want? They are more focused on exactly what is going on in the operative field than anyone else, and they can lean closer or ask us to repeat our request. We need a better way to talk to everyone else in the room! The anesthesiologist who is balancing multiple tasks and the OR nurse who is at least several steps away from the surgeon. What are the potential roadblocks or negative consequences associated with implementation? · Potential for misinterpretation of signals…someone is expecting a pickup and they’re handed a scalpel, which is quickly brought into the field and creates an injury. · The inability of the surgeon to create the signal if both hands are working. · If verbal communication is eliminated, the tech has to constantly watch the surgeons hands, which prevents them from doing other manual tasks, such as loading clip appliers, returning needles to the count box, receiving freshly opened materials from the scrub nurse, etc After all that, I’m not rendering a final verdict. This is an innovative and intriguing concept with a lot of potential. It should be considered and trialed while ensuring that its benefits outweigh the negative impacts before wide-spread implementation. 1. Yánez Benítez C et al. Impact of Personal Protective Equipment on Surgical Performance During the COVID-19 Pandemic. World J Surg. 2020 Sep;44(9):2842-2847 . 2. Hampton T et al. The negative impact of wearing personal protective equipment on communication during coronavirus disease 2019. J Laryngol Otol. 2020 Jul;134(7):577-581 . 3. Leyva-Moraga FA et al. Effective surgical communication during the COVID-19 pandemic: sign language. Br J Surg. 2020;107(10):e429-430 4. Chan A. Should we use an “aerosol box” for intubation? Life in the Fast Lane. 2020 Jul. https://litfl.com/should-we-use-an-aerosol-box-for-intubation/ Previous Next

< Back Definitions Common Abbreviations ACS- Acute care surgery. Field of surgery that encompasses trauma, emergency general surgery and surgical critical care. APP- advanced practice provider. Includes physician assistants (PA) and nurse practitioners (NP). ICU- intensive care unit. Higher-acuity (sicker) patients requiring closer monitoring (continuous evaluation of vital signs), more invasive or more frequent interventions (mechanical ventilation, multiple cardiac medication infusions). CRNA- certified registered nurse anesthetist. CRRT- continuous renal replacement therapy. EGS- Emergency General Surgery. GCS- Glasgow Coma Scale. IV- intravenous. MCC- motorcycle crash/ collision. MVC- motor vehicle crash/ collision. SCC- surgical critical care. Common Personnel - Attending physician- most senior physician caring for a patient. - Bedside nurse- the nurse who provides the direct patient care, including assessing a patient's current clinical status, providing medications, interact with other teams that see the patient such as physical therapy or the wound care team, placing urinary catheters and monitoring urine output, communicating with the patient's physician team, providing patient education. - Chief Resident- resident in their final year of residency training. - Fellow- a physician that has completed preliminary training and undertakes advanced training in a subspecialty. Typically follows residency graduation, although Surgical Critical Care can be completed prior to graduating from surgical residency. - Intern- a physician in their first year of residency training following medical school graduation. Common Procedures - Arterial line placement- similar to an IV, this is a skinny catheter, but instead of being in a vein, it’s placed in an artery. This allows continuous monitoring of blood pressure and allows repeat labs, specifically arterial blood gas to assess respiratory status. - Bronchoscopy- use of a small camera (think of a really skinny colonoscope) to examine the airways of the lungs, take a specimen for culture or remove an obstruction. - Central line placement- placement of a large catheter into a large vein in the neck, under the clavicle (collarbone), or in the groin. The purpose is similar to an IV (intravenous) line, which is commonly placed to provide medication, fluids, or draw blood. A central line is larger- more drips can be connected to it, it can be kept in place longer than a peripheral IV, and it can allow delivery of special medications. - Intubation- placement of a plastic breathing tube (endotracheal tube) through a patients mouth, into their trachea (airway). Patients receive sedation medication and paralytic medication (medication to prevent muscle movement. This is commonly used for patients who are unconscious or are having breathing difficulties. It is also commonly used while patients are undergoing surgery - Laparotomy- vertical incision on the abdomen to allow examination of the organs in the abdomen. Also known as an “exploratory laparotomy” or “ex lap”. - Ostomy creation- in the unplanned setting, patients who undergo emergent surgery for trauma or bowel ischemia/ perforation, a segment of the bowel might be removed, reconnected or repaired. These patients are at a higher risk for their bowel connection or repair to fall apart (known as an anastomotic leak). To prevent this, sometimes it is safer to divert the stool toward an opening in the skin to allow stool to pass outside into a bag, instead of moving into the intestine that was repaired/ reconnected. - Ostomy reversal- reconnection of the bowel after a patient has recovery from emergency surgery. The bowel is reconnected (so the patient will now pass stool normally) and the skin opening is closed. - Percutaneous endoscopic gastrostomy tube (PEG)- creation of a connection directly through the anterior abdominal wall into the stomach to allow feeding without requiring a tube in the patient’s nose. - Thoracotomy- incision on the chest to allow access to the organs in the chest (heart, lungs, esophagus). - Tracheostomy- creation of a connection directly from the front of the neck to the trachea (airway). A short curved tube is placed in the open, and the endotracheal tube (breathing tube) is removed from the mouth. Common definitions - Rounds- the process of evaluating and examining patients currently in the hospital. Previous Next

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

3 Everybody Lies Big Data, New Data, and What the Internet Can Tell Us About Who We Really Are - The staggering amount of data available and the power to make predictions. - Internet search bars have entered society as a secret place to ask our most urgent/ personal/ embarrassing questions without risk of guilt or shame from others discovering intimate details about us. People lie on job interviews, online surveys, and almost anywhere they are at risk of being revealed, which introduces a significant bias in database queries. In contrast, there is no motivation to lie to the anonymous search bar. - Evaluating internet searches can reveal an infinite amount of information about society as a whole. Monitoring internet searches during presidential addresses, evaluating searches for unemployment offices, what to say on first dates- there is so much data that can be harnessed to understand society. 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

Disclaimers for Vignettes Disclaimers This website is provided for educational and informational purposes only and although every effort has been made to present accurate information, this is not a substitute for professional advice. Always seek guidance from a qualified healthcare provider or physician for inquiries regarding medical conditions, treatments, or before embarking on any new healthcare regimen. Never disregard professional medical advice or delay in seeking it due to information found here. If you think you may have a medical emergency, call 911 or go to the nearest emergency room immediately. No physician-patient relationship is created by use of this website. The practice of medicine relies on using the best available evidence, but clinical scenarios often lack clear-cut answers. Every clinical situation is unique, and no single solution applies universally. Clinical guidelines attempt to provide recommendations that apply in most situations, but that are not one-size-fits-all solutions and they do not replace clinical judgment. The infinite variety of patient, disease, and environmental factors influencing clinical decision-making cannot be fully accounted for in medical literature. Therefore, any variance in the approach of physicians from what is presented here does not necessarily signify an error on their part. Some of the images on this website contain graphic content that may be disturbing or distressing to some audiences. Viewer discretion is advised. HIPPA- vignettes are presented to provide clinical education, with considerable care to prevent any patient from being identified. Protected health information and patient identifiers (name/ location/ date/ occupation/ contact information/ identifiable photos/ numerics such as SSN/MRN/insurance) have been withheld. Unique details have been removed from text and images. Details that don't impact the clinical case, such as age and gender, have been modified to obscure each patient's identity. Many stories are heavily modified to highlight the key learning points and some scenarios are complete fabrications. The scenarios span my entire 17 years of experience in the medical field, and they are seen on a routine basis in our field. I have not shared one-of-a-kind or sensational cases because the risk of disclosing identifiable details heavily outweighs any potential educational benefit. The views, opinions, and assertions expressed herein are those of the author and do not reflect the official policy or position of the Department of Defense. These scenarios are not designed to portray the comprehensive evaluation and management of acute care surgery patients. Many common steps are omitted, as the intent is to highlight unique learning points for different clinical scenarios. Trauma scenarios DO NOT teach all the basic principles of ATLS, so there is a minimal repetition of basic principles (primary and secondary survey). Any of the products found on this website are not specific endorsements. I do not receive any monetary compensation or non-monetary incentives for the sale of any items seen here.