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10 Loonshots How to Nurture the Crazy Ideas That Win Wars, Cure Diseases, and Transform Industries - S type and P type loonshots. Innovators (creating loonshots) have to co-exist with the “businessmen”- you can’t just segregate different groups. The innovators need the company to make a profit so they can continue to take risks and make discoveries. And the business needs to nurture loonshots. - In case you were wondering how polarizing crystals were discovered. Or check out this article in Science magazine. - Bad decisions may occasionally result in good outcomes. But you need to analyze wins- you might not be so lucky next time. - Good decisions may result in bad outcomes. You made the best decision with the information at your disposal. In those same circumstances, you’d make that same decision. - How do crickets synchronize their chirps? - Percolation. A mathematical explanation for predicting events based on an inherent variable. - How do forest fires spread? Relevant variables- the distance between trees, humidity, wind. - How do pandemics start? How appropriate…depends on the proximity of individuals. - Phase transitions - Why do traffic jams occur? Just above a certain density of cars on the roads→ jam. - Emergence- innate characteristics of how a group functions based on the size (ie what patterns shift after the group reaches a size, although the precise size is variable for groups) While individuals remain puzzles, man in the aggregate becomes a mathematical certainty. Meaning- group dynamics are universal, regardless of the characteristics of the group members. Previous Next

[Editorial inspired by @kari_jerge] Why Don't They Believe Us? < Back [Editorial inspired by @kari_jerge] Seen on Twitter recently: Troll: I demand pictures of your full ICU to prove to me it’s full Female surgeon: None of us owes you a damn thing. Especially not pictures that will get us fired. But I’ll get right on that… What do you do if you accidentally injure yourself while working or making home improvements? Do you call 911 or have someone drive you to the ER? What do you do if you have high blood pressure, or diabetes, or depression? Do you go to a primary care doctor? What do you do if you have severe arthritic hip pain that doesn't resolve with conservative (non-operative) management? Do you consider talking to an orthopedic surgery about a hip replacement? I don't know what portion of the population inherently trust the medical community, but for the remainder of this editorial, I will presume that it's a majority. For those that don't, this doesn't apply. If you don't trust modern medicine, I won't convince you that you should trust our reports about this pandemic. Let's assume you accept modern medicine, including visiting the emergency department, having a primary care doctor, taking prescription medicine, and any of the other various diagnostic tests, consultations, and treatments. If this is the case, why would you think we would voluntarily try to deceive you about the capacity and occupancy of our ICU facilities? Why would so many medical community leaders actively speak out with a nearly singular voice to spread a lie? Ranging from the widely known Dr. Sanjay Gupta to a wide assortment of medical providers in many specialties. We have nothing to gain from building this whole façade. This isn't just a few people speaking up. This is a monumental effort to warn people. Social media has given a voice- and many have worked very hard to dispel the myths spread by many loud voices that continue to spread falsehoods. We have nothing to gain. You trust us to save your life when you have a heart attack, need emergency surgery, or care for you when you're severely ill from any matter of diseases. We haven't changed as a community to collectively spread these myths. It really is as bad as we say. We genuinely don't get paid more for patients who die from COVID. We don't have adequate PPE. We aren't lying. If you continue to deny reality, we will still care for you or your family and friends, in the unfortunate case you become ill, because that's what we do. We are just hoping that we will have the resources you need. And if we stretch our personnel any thinner, we will not have enough nurses and providers to care for you. We are the last hope. Don't make choices you'll regret. Previous Next

What is ACS? A day in the life of an Acute Care Surgeon. FAQs. ICU Rounds. Trauma Surgery. Acute Care Surgery What is Acute Care Surgery? Medicine, particularly surgery, has become increasingly specialized, with providers developing progressively narrower expertise. Previously, surgical critical care fellowship was the primary pathway for specialization in the management of critically ill and injured patients. Management of "sick" surgical patients, regardless of the underlying surgical etiology, requires flexibility in addition to width and breadth of knowledge to manage a wide spectrum of clinical challenges, including deranged physiology and complex surgical pathology. Balancing an acutely hemorrhaging patient, an elderly patient with severe poly-trauma, a ventilator-dependent patient with an acute abdomen...the list is endless. Acute Care Surgery (ACS) was brought about to ensure that there is access to a specialized physician that can manage a spectrum of critically ill patients, including trauma, emergency general surgery (EGS), and surgical rescue . Surgical rescue involves the management of procedural complications or clinical situations that require emergent surgical intervention: "airway emergency, hemorrhage, intestinal obstruction, perforated viscus, tube/line/device dysfunction, uncontrolled sepsis with a surgical etiology, visceral ischemia, and wound complication." Management can include the following interventions: "airway intervention, biliary repair/ reconstruction, bowel resection, hernia repair, hemorrhage control, source control of infection, surgeon-guided resuscitation, tube/line/device repair, and wound debridement."(1) Pillars of Acute Care Surgery 1. Kutcher ME et al. Surgical rescue: The next pillar of acute care surgery. J Trauma Acute Care Surg. 2017;82(2):280-286. 2. Kutcher M.E., Peitzman A.B. (2017) A History of Acute Care Surgery (Emergency Surgery). In: Di Saverio S., Catena F., Ansaloni L., Coccolini F., Velmahos G. (eds) Acute Care Surgery Handbook. Springer, Cham. Who Is Our Patient Population? Read More A Day in the Life of an Acute Care Surgeon Read More What happens during Surgical ICU (SICU) Rounds? Read More Who is on the Trauma Team? Read More What happens in the trauma bay? Read More The Trauma Bag Read More Frequently Asked Questions Read More Definitions Read More More Information on Acute Care Surgery Read More

Brain Death and Organ Donation End of Life Issues < Back Brain Death and Organ Donation Death can be uncomfortable and challenging to face/ navigate. Here are some of the situations that can arise surrounding the issue of death and organ donation. - Is resuscitating a patient with a devastating TBI for organ donation preservation justified? It may seem opportunistic and NOT focused on the dignified care of the patient- but it the patient’s desire would be to donate, preserving that option DOES honor their wishes. - If a patient is declared dead, specifically brain dead or death by neurologic criteria, and they previously expressed desire to be an organ donor (such as registration with an OPO or indicating their desires on their drivers license), legally the family can’t prevent the patient from donating. Even if the family opposes it, legally the patient should proceed to donation. But what about the risk of “bad press”? You’re honoring the patients wishes although that fact may be less apparent to the public compared to the anger expressed by the family members that the hospital “stole their loved one’s organs against their wish” or even worse, implying that the hospital “allowed” the patient to die so they could use their organs. - You don't need consent to perform a brain death test. Previous Next

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

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

< Back Before Surgery American College of Surgeons (ACS) Operation Brochures for Patients Patient Education: Preparing for Your Surgery How Can I Be Strong for Surgery? Strong for Surgery is a program that works with surgeons and hospitals to provide tools like checklists that surgeons can use to assess your risks in four target areas: nutrition, blood sugar control, smoking cessation, and medications. You can lower your risk by being better prepared for your operation. NSQIP Surgical Risk Calculator Disclaimer: The ACS NSQIP Surgical Risk Calculator estimates the chance of an unfavorable outcome (such as a complication or death) after surgery. The risk is estimated based upon information the patient gives to the healthcare provider about prior health history. The estimates are calculated using data from a large number of patients who had a surgical procedure similar to the one the patient may have. 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

Gadgets and Tools < Back My Favorite Things Gadgets and Tools Packing and Travel These Hopsooken packing cubes make organizing your suitcase a breeze. These noise-canceling headphones effectively drown out the rumbling noise of airplanes at a reasonable price. The Patagonia Black Hole Duffel . Multiple sizes available. Very spacious. Easily converts to a backpack when traveling for easy carrying. Therma-Rest compressible pillow from REI Quick Dry Towel from REI Cleaning Products Goo Gone - for removal of excess sticky residue. Greased Lighting - great for stain removal. It can be purchased at Lowes/ Home Depot. Kitchen Storage containers for baking ingredients. These wide-mouthed containers let you pour baking ingredients from their original bags with minimal mess. It’s also very easy to use a scoop directly into the containers when baking. This is a perfect bread box ! When I leave a loaf of bread in its original package, it gets moldy pretty quick- but if I put it in this box, it lasts much longer. Bakers Rack . My current kitchen has much less cabinet space than what I have grown accustomed to, so I sought out a solution to store my baking supplies that take up my counter space. Now my bread maker, mixing bowls, large metal colander, and rolling pin no longer hide above the fridge or clutter my counters. Writing Accessories A hand-held non-electronic datebook . After years of relying on electronic resources to maintain my schedule, I finally made the switch to a device that allows me to create/ maintain a schedule, both weekly and monthly formats. Also has blank pages at the back, perfect for lists, notes, etc. Frixion Erasable pens “We've all had a shower thought or two…They're the miniature epiphanies that occur when your brain is occupied with doing something else, but suddenly you realize that you've come up with a totally unique way of thinking.” And sadly, once we step out of the shower, the great idea seems to vanish. Thankfully, someone developed this notepaper that doesn’t fall apart in the shower! A roll of self-adhesive whiteboard paper to post to your wall, your fridge, your mirror, wherever. Handy in the kitchen- plan meals, add items to put on your grocery list when you discover you’re running low or just write reminders. My favorite highlighters when writing notes. They aren’t too heavy, so they don’t bleed or run. They are dual-tipped, with a broad highlighter on one end and a narrower tip for writing on the other end. My favorite pen . Fine tip to allow precise, small writing. Trello - a user-friendly free application with multiple functions. I use it to store frequently used documents to allow quick reference. It is also a very convenient way to create and manage lists among teams so everyone has easy access. Check it out, you might find it useful. Things for the Ladies I don’t wear many thin garments or revealing necklines, so I don’t often have to struggle to find a bra that remains concealed. However, on the rare occasion that I wear a dress or top that isn't conducive to wearing a bra, these reuseable cover-ups are incredibly handy for maintaining decency. If you're interested in making the transition from disposable monthly products, check out this product . This is the only one I've tried, so I can’t compare them, but it's worked well for me. Lume Deodorant . Doesn’t stop sweating, but eliminates odor. Highly highly recommend. If you find yourself having to unclog the shower drain with clumps of hair, you might want to check out the Tub Shroom . Previous Next

< Back GI Dysmotility...pending GI Dysfunction Previous Next