< Back Anal Fissure What is an anal fissure? Patient information: Anal fissure [American College of Colon and Rectal Surgeons] Patient education: Anal fissure (Beyond the Basics) [UpToDate] Trauma from hard stool (constipation) creates a tear in the anoderm distal to the dentate line. Pain leads to internal sphincter spasm, setting up a vicious cycle! Symptoms- severe pain during and immediately following a bowel movement ("like pooping glass", "passing a razor blade"), blood on toilet paper with wiping. This often leads to fear of having bowel movements. Pain leads to muscle spasm→ higher pressure→ vicious cycle. Diagnosis- classic history is almost enough, but pain with effacement of the buttocks and visualization of a tear in the anoderm confirms. Don’t torture them with a digital rectal exam! On exam, typically seen in the posterior midline. If a fissure is seen in a different location, consider IBD, trauma, infection (Tuberculosis, sexually transmitted diseases), cancer. Source: UpToDate Images: Anal Fissure Anatomy What is conservative management for an anal fissure? See “ Anorectal Disease: How do I prevent anorectal disease? ” Improving bowel habits is the first-line treatment for an anal fissure. See patient handouts below. The majority of patients with an acute fissure heal with conservative management. If a fissure has been present for a long time, it is less likely to heal with conservative therapy. Sitz baths- fill a tube with water as warm as you can tolerate, and soak your bottom after every bowel movement and at least 3 times per day. Topical compounds- nitrates, calcium channel blockers→ relax muscle→ improved blood flow→ allows healing. Local anesthetics can also improve symptoms during the healing process. Avoid suppositories, Tucks pads, and Preparation H. These would be painful and won’t treat the disease. This is why diagnosis is vital. Patient Info- Anal Fissure .pdf Download PDF • 59KB Patient Info- Fiber Guide .pdf Download PDF • 68KB What is the operative management for an anal fissure? For the few patients who fail a trial of conservative therapy, surgical intervention can provide relief. Botulinum toxin (Botox) blocks neuromuscular function leading to muscle relaxation. Yes, this is the same Botox that is used to treat wrinkles. Low risk of complications. Lateral internal sphincterotomy is the treatment of choice for chronic fissures that have failed to resolve with other interventions. More successful healing compared to other interventions. Risk of incontinence (inability to control the passage of gas and stool). If incontinence occurs, the inability to control gas is more common than the inability to control liquid stool, which is more common than the inability to control solid stool. Previous Next

< Back Don't mess with the Pancreas A 47-year-old female with epigastric abdominal pain and nausea presents to the ER for evaluation. She is an otherwise healthy female, with no prior surgical history. On further questioning, her pain started 3 days ago and radiates toward her back. It has persisted and wasn't relieved with over-the-counter Tums, Gas-X, and Pepcid. She has had nausea but no vomiting. She has had minimal appetite over the past few days. Her history is otherwise unremarkable with no prior similar symptoms. On exam, she is uncomfortable but not in acute distress. HR 112, BP 112/63, T 99.1, O2 sat 99% on room air. Her abdominal exam is notable for focal tenderness in the epigastrium. What is on your differential and what is your initial workup? Peptic ulcer disease, esophagitis, hepatobiliary pathology (cholecystitis, hepatitis), pancreatitis, bowel obstruction, GERD, and bowel perforation. Labs- CBC, amylase, lipase, lactate. Imaging- acute abdominal series, possibly CT scan. Her labs are notable for a WBC of 11K, markedly elevated lipase, normal bilirubin and normal renal function. Her acute abdominal series shows non-specific bowel gas pattern with minimally dilated loops of small bowel. Right upper quadrant ultrasound revealed gallstones without evidence of acute cholecystitis. Based on the patients clinical presentation and lab findings, she is diagnosed with acute gallstone pancreatitis and was admitted to the surgical service. What are your initial goals of management? Pain control, IV fluid resuscitation. NPO until pain is improving. NGT if nauseated/ vomiting. Monitor vitals and organ function (urine output, labs). On her second hospital day, she developed worsening nausea/ vomiting, so an NGT was placed to decompress her stomach. Over the next few days, she has ongoing low grade sinus tachycardia, and then she developed intermittent low grade fever and mild leukocytosis. At that point, a CT scan is obtained. CT abdomen and pelvis https://video.wixstatic.com/video/3b6ff6_7d78015ba7b5430bb996145d60f8b0d6/360p/mp4/file.mp4 The scan reveals peripancreatic inflammation with peripancreatic stranding, gland edema and hypoperfusion. There is also simple appearing peripancreatic fluid. Over the next few days, the patient developed worsening pain and an uptrend in her leukocytosis. She is mildly hypotensive and she is urinating less frequently. When a Foley catheter is placed, she has a small volume of concentrated urine in the collection bag. She is transferred to the ICU and a Dobhoff tube was placed for post-pyloric enteral feeding. Over the next two days, she develops fevers, an increasingly oxygen requirement and persistent pain. A repeat CT scan was obtained. Follow-up CT abdomen and pelvis https://video.wixstatic.com/video/3b6ff6_e3134e03b3f242a291efd6dbc2e187e2/360p/mp4/file.mp4 There is evidence of progression of her pancreatitis. There are bilateral pleural effusions as well as worsening intra-abdominal free fluid. There is evidence of non-perfusion of the midportion of her pancreas, consistent with pancreatic necrosis. She remained in the ICU over the next several days. She did not clinically deteriorate and her pain slowly resolved. She had persistent high-volume output from her NGT. Why would she have high volume output in her NGT? Gastric outlet obstruction from peripancreatic fluid collection or necrosis. Ileus from ongoing intra-abdominal inflammation. Her distension improved with NGT decompression, and she continued to have bowel function. She was started on post-pyloric enteral feeds via a nasojejunal tube, and this was continued for the next month, awaiting for the acute necrosis to wall-off and develop a rind. Management of Acute Pancreatitis Etiology Gallstones and alcohol account for the vast majority of cases of pancreatitis. Other causes include hypertriglyceridemia, medication, ERCP, and hypercalcemia. Diagnosis Clinical presentation- epigastric pain, sometimes radiating to the back or shoulder. Nausea/ vomiting. Labs- elevated amylase/ lipase at least 3x normal Radiology- peripancreatic inflammation on contrast CT of abdomen. CT scan is not always mandatory on admission, but its commonly obtained for patients who have significant enough disease that they warrant a surgical consult. CT is also useful to rule out other pathology if the diagnosis is unclear. Clinical Course Most patients (about 80%) with acute pancreatitis suffer only mild disease and have resolution of symptoms without sequalae. The remaining 20% progress to moderate or severe pancreatitis, which is defined by the development of peri-pancreatic fluid collections or necrosis (sterile= moderate, infected= severe), or organ failure (transient= moderate, persistent= severe). Patients with organ dysfunction require ICU admission. Initial management Fluid resuscitation and ensuring adequate pain control. Nutritional support is also important, and patients are allowed to eat. Enteral nutrition should be initiated if the patient doesn't have adequate intake over the first few days. Close monitoring for development of sequalae. Patients are at risk for ARDS, abdominal compartment syndrome and infection. Assessment of Disease Severity Ranson's Criteria: Classic criteria for estimating pancreatitis severity[1] Admit data: WBC >16K, age >55, glucose >200, AST >250, LDH >250 48 hours: ↓Hct >10%, ↑BUN >5, Ca <8, PaO2 <60, Base deficit >4, >6L IVF. CT Severity has also been used to grade pancreatitis- inflammation, fluid collections and necrosis.[2] Management of Complicated Pancreatitis- Fluids Collections, Necrosis, Infection Diagnosis and Classification of peri-pancreatic fluid collections and necrosis [3] Acute interstitial edematous pancreatitis Less than 4 weeks, the fluid collection is an acute peripancreatic fluid collection . After 4 weeks, it becomes walled-off/ encapsulated and is a pancreatic pseudocyst . Acute necrotizing pancreatitis [non-enhancing pancreatic parenchyma] Less than 4 weeks, the fluid collection is an acute necrotic collection . After 4 weeks, it becomes walled-off/ encapsulated and is walled-off necrosis . Infected pancreatic necrosis- diagnosed by air in the necrosis, clinical symptoms consistent with infection and confirmed by aspiration and culture. A negative culture does not definitely rule out infection, so in the appropriate setting of clinical deterioration, there must be a high index of suspicion for infection. Indication for Antibiotics Antibiotics are NOT indicated for severe pancreatitis or pancreatic necrosis as a prophylaxis for infection.[4, 5] They are only indicated in known or highly-suspected infected necrosis. The antibiotics chosen must penetrate pancreatic tissue to be effective- quinolones and carbapenems are both broad-spectrum antibiotics (cover gram positive and gram negative) that penetrate pancreatic tissue. Carbapenems also cover anaerobes. Metronidazole covers gram negatives. Regimen: carbapenem or quinolone + metronidazole. Also consider antifungal coverage in severely ill patients.[6] Diagnosis of Infected Necrotizing Pancreatitis Infected pancreatic necrosis can be a challenging clinical diagnosis because the inflammatory state associated with pancreatitis can present with similar signs and symptoms, including fever, tachycardia, leukocytosis and ileus. CT evidence of air in the pancreatic necrosis is highly suggestive of infection, although absence of air does NOT definitively rule out infection. Fine-needle aspiration (FNA) can be used to obtain a sample for culture. There is a risk of infecting a sterile necrotic collection by performing an FNA, so this requires careful clinical decision-making. Management of Infected Necrotizing Pancreatitis These patients need broad spectrum antibiotics. Some patients may improve with antibiotics alone, but a drainage procedure is often needed. Percutaneous IR drain placement has a low rate of complications, but frequently fails to fully resolve the infection. Upsizing the drain or proceeding to more invasive intervention (see below) is required if that patient deteriorates despite drain placement and antibiotics. Previously, open necrosectomy was the standard. This is a highly morbid procedure, that requires maintaining an open abdomen, repeat washouts, and a prolonged ICU stay. Now, the step up approach is being increasingly utilized to manage these patients less invasively with similar or better outcomes (percutaneous retroperitoneal drainage or endoscopic transgastric drainage, endoscopic necrosectomy, followed by retroperitoneal necrosectomy).[7-10] Management of peri-pancreatic fluid collections [11-13] Enteral nutrition and pain control. A trial of a regular diet is appropriate, but if the patient is able to tolerate a regular diet, supplemental nutrition is required. Enteral nutrition is ideal, as it is associated with improved outcomes compared to TPN. Enteral access distal to the 3rd portion of the duodenum may theoretically avoid stimulation of the pancreas, but there is no evidence that jejunal feeds are superior to gastric feeds. However, depending on the location of the fluid collection, gastric outlet obstruction is a potential complication. Ideally, post-pyloric access would be obtained prior to obstruction, and can be used for long-term feeding while the fluid collection is allowed to resolve/ mature. Most resolve without intervention. As long as the patient is not systemically ill, drainage of pancreatic necrosis should be delayed as long as possible, ideally 6-8 weeks. Goal is to avoid procedural intervention until the fluid/ necrosis have become walled off, and then only intervene if the patient remains symptoms (pain, early satiety). However, if the patient clinically worsens, earlier intervention is necessary. Open pancreatic necrosectomy is associated with significant morbidity and mortality. An algorithm starting with least invasive (percutaneous or endoscopic drainage) and progressing to more invasive if the patient continues to do poorly is associated with decreased morbidity and mortality. References Ranson JH et al. Prognostic signs and the role of operative management in acute pancreatitis. Surg Gynecol Obstet. 1974 Jul;139(1):69-81. Balthazar EJ et al. Acute pancreatitis: value of CT in establishing prognosis. Radiology. 1990;174(2):331-336. Banks PA et al. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013 Jan;62(1):102-11. Dellinger EP et al. Early antibiotic treatment for severe acute necrotizing pancreatitis: a randomized, double-blind, placebo-controlled study. Ann Surg. 2007 May;245(5):674-83. Leppanieme A et al. Executive summary: WSES Guidelines for the management of severe acute pancreatitis. J Trauma Acute Care Surg. 2020 Jun;88(6):888-890. Howard TJ. The role of antimicrobial therapy in severe acute pancreatitis. Surg Clin North Am. 2013 Jun;93(3):585-93. van Santvoort HC et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med. 2010 Apr 22;362(16):1491-502. van Brunschot S et al. Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial. Lancet. 2018 Jan 6;391(10115):51-58. Luckhurst CM et al. Improved Mortality in Necrotizing Pancreatitis with a Multidisciplinary Minimally Invasive Step-Up Approach: Comparison with a Modern Open Necrosectomy Cohort. J Am Coll Surg. 2020 Jun;230(6):873-883. Boxhoorn L et al. Immediate versus Postponed Intervention for Infected Necrotizing Pancreatitis. N Engl J Med. 2021;385(15):1372-1381. Tyberg A et al. Management of pancreatic fluid collections: A comprehensive review of the literature. World J Gastroenterol. 2016 Feb 21;22(7):2256-70. van Dijk SM et al. Acute pancreatitis: recent advances through randomised trials. Gut. 2017 Nov;66(11):2024-2032. Maurer LR et al. Contemporary Surgical Management of Pancreatic Necrosis. JAMA Surg. 2023;158(1):81. 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

< Back What happens during Surgical ICU (SICU) Rounds? This does NOT reflect the practice pattern of every SICU. All the components must be addressed, but there are many variations on how they are incorporated into the daily routine. Flash Rounds A multi-disciplinary process that includes the charge nurse, respiratory therapist, clinical nutritionist, physical therapists/ occupational therapists, clinical case manager, and a senior member of the team (attending, fellow, APP). Focused on ensuring that each patient has daily goals and a plan from each of the team members, ensuring that key issues are addressed early instead of waiting until after rounds (nutrition, plans for ventilator weaning, disposition planning, etc.). Working Rounds A multi-professional process that includes the bedside nurse, "learners" (broad term to include students, residents, advanced practice provider (APP) fellows), as well as the APPs (nurse practitioners (NP) and physicians assistants (PA)) and a clinical pharmacist. The team is led by the attending physician or critical care fellow. Engagement and communication by all team members are encouraged. After reviewing overnight events, a system-based approach is used to methodically evaluate the patient's current clinical status and then develop a management plan. 1. Systems-Based Rounds- presented by resident or APP - Neurologic- assessment of mental status, including the Glasgow Coma Scale (GCS), Richmond Agitation-Sedation Scale (RASS), etc. Current sedation and analgesia regimen. Review relevant radiologic imaging. - Cardiovascular- relevant vital signs and hemodynamic monitoring parameters, including trends and ranges. Review current cardioactive medication. - Pulmonary- current ventilator settings, relevant laboratory values (arterial blood gas), relevant radiologic imaging (chest radiograph). - Gastrointestinal- physical exam. Assess nutritional status (tolerating enteral nutrition, contraindication for enteral feeds, plan for parenteral nutrition). Review relevant radiologic imaging (abdominal radiograph). - Genitourinary/ Renal- review intake/ output (I/Os). The total volume of fluid intake (intravenous fluids, nutrition, blood, antibiotics, etc.) and fluid output (urine, stool, drains, etc.). Relevant laboratory values (basic metabolic panel). - Endocrine- review glycemic control. - Hematology- assessment of coagulation status or abnormal blood counts (hemoglobin, platelets). - Infectious Disease- physical exam- fever and evaluation of all possible infection sources (catheters, wounds, respiratory secretions). Review relevant laboratory values (white blood cell count, culture results), review current antibiotic therapy. - Prophylaxis- review needs for venous thromboembolism and stress ulcer prophylaxis. 2. A-F Bundle presentation by bedside nurse [SCCM ICU Liberation Bundle] - Assess, prevent, and manage pain - Breathing (Spontaneous awakening and breathing trials) - Choice of analgesia and sedation - Delirium assessment, prevention, and management - Early mobility and exercise - Family engagement 3. Develop a management plan based on comprehensive patient assessment. Previous Next

Advanced Practice Nurses to begin coming to Code Blues and supervising residents Code Blue: Who's in Charge? < Back Advanced Practice Nurses to begin coming to Code Blues and supervising residents I recently came across this article on Twitter and wrote my reply as soon as I read it. But as I was preparing to post this, I did a little more background research on the article. Let's start with the source- the website is called "MidlevelWTF ". The tagline is- "Exposing midlevel incompetence in the fight to ensure patient safety and preserve physician-led, physician-supervised medicine." The author's user name/ Twitter handle is MidlevelWTF; motto: "an actual doctor, with an actual MD." In light of this, the tone of the article makes much more sense. I'm disgusted to discover that a physician has dedicated their time/ energy to specifically target and defame APPs. Reply I disagree with a policy that formally designates a nurse practitioner to supervise any resident who runs a code. It's not appropriate to assign anyone else the authority to unilaterally overrule the decisions of the code leader. Codes need 1 leader- this is typically not the most junior person in the room, but someone in the middle or upper level of their training- a midlevel or senior resident. This doesn’t mean leaders can’t get recommendations from others. The more senior personnel in the room are welcome to provide advice- if there is egregious incompetence, which I would guess is the exception far more than the rule, someone, such as an attending or fellow or senior resident, can take over the role as leader. Working with the premise that the leader is competent, correcting a mistaken dose, helping develop a differential and general troubleshooting are all in the patient's best interest. These are also integral to closed-loop communication, and shouldn't be considered undermining or met with resistance. Team members should be able to speak up freely without having to worry about being yelled at for correcting another provider who is potentially more senior. The problem with this policy lies in the disruption of the team dynamics- adding another layer of "leadership" by formally assigning someone to have authority over the team leader creates confusion. If there is a contradiction, does the team listen to the leader or the "assigned" supervisor, who could reasonably have less experience than the resident? I've gladly welcomed advice from those with more experience than me during a difficult situation, and I trust them to speak up if they see something amiss. I trust all the non-physicians who care for our patients in my absence, and I trust them to call me if there is any concern; I hope they will feel empowered to do this in a code situation as well. So I support the author's general stance that the policy is inappropriate. However...I take great offense at this article. Implying that nurse practitioners (NPs) are minimally qualified and poorly educated is insulting and severely erroneous. Worst of all, the writer implied that a midlevel might decide to call it quits on a code “because they didn't feel like doing it anymore.” Absolutely inflammatory. Implying that any healthcare professional would be lazy or bored and just give up is preposterous. I have worked with many APPs (advanced practice providers), which includes NPs and PAs (physicians assistants) in the ER, on the inpatient wards, in the operating room, in the ICU, and in clinic. I have found them to be phenomenal teammates, motivated and eager to continually learn about how to best care for patients. Yes, some are less competent than others. But this is equally true of all healthcare professionals. I would gladly have a competent NP run a code if they were at the bedside at felt comfortable/ empowered to do so. While I would never designate a non-physician to oversee a resident running a code, I would similarly never expect a resident to take over the role of team leader from a competent NP or PA. As a fellow, during my time in the ICU, I would gladly let either an APP or a resident run the code, depending on availability and comfort level. I would be readily available and provide input when needed such as when the decision-making process extends past the algorithm of ACLS and into specific patient scenarios. In addition, if the patient needed an emergent/ urgent procedure, I was free to perform or assist while those procedures were being performed, as the NP/PA or resident continued to manage the overall code situation (meds, compressions, US to examine for cardiac activity, calling for MTP, etc). So I disagree with the policy, but I am deeply disappointed in the way the author chose to make petty accusations to undermine APPs and justify their disagreement with the policy. It's disappointing that a professional would stoop low enough to attack the character of our teammates. Previous Next

Medical Literature Evidence-Based Medicine After you have established a firm foundation of the basics of your chosen specialty, you're ready to develop regular habits to stay up to date on the newest research. Evidence-based medicine is the basis of high-quality patient care, but it can seem overwhelming to try to keep up with the ever-growing body of research. There are countless journals, and it would be time-consuming to search them regularly. So how does one go about navigating the vast ocean of available data? Registering for email alerts is a simple way to get notified when there are new publications. With a quick skim through the article titles to see if anything is relevant, followed by a review of the abstract/ article itself, you can be on the cutting edge of the latest information in your field. Several require individual registration, but it's a very simple and quick process. Many journals require a subscription, often available through your medical school or hospital library. If you are military, you have access to AMEDD Virtual Library (abundant medical resource collection). Thankfully, three publishers (LWW Wolters Kluwer , Springer and Elsevier ) have centralized their journals, so you can quickly subscribe to several journals [these journals are designated by L, S or E]. Medicine and Critical Care Journal of the Ameri can Medical Association New England Journal of Medicine Intensive Care Medicine Critical Care Medicine (L) Current Opinions in Critical Care (L) Journal of Intensive Care (S) Critical Care (S) Journal of Critical Care (E) Critical Care Clinics (E) Surgery World Journal of Surgery World Journal of GI Surgery JAMA Surgery J Gastrointestinal Surg Advances in Surgery Annals of Surgery (L) Annals of Surgery Open (L) BMC Surgery (S) Surgery (E) American Journal of Surgery (E) Journal of the American College of Surgeons (E) Surgical Clinics of North America (E) Advances in Surgery (E) Trauma and Emergency Surgery European J Trauma and Emergency Surgery Trauma Surgery and Acute Care Open Journal of Trauma and Acute Care Surgery (L) World Journal of Emergency Surgery (S) World Neurosurgery (E) Other Specialities Journal of Neurotrauma World Journal of Cardiology JAMA Cardiology JAMA Neurology JAMA Network Open Anesthesia and Analgesia (L) Current Opinion in Anesthesiology (L) Current Opinion in Clinical Nutrition (L) Current Opinion in Infectious Diseases (L) Current Opinion in Neurology (L) Diseases of the Colon and Rectum (L) Journal of the American College of Cardiology (E)

Surgery trainee education. Trauma surgeon. Acute Care Surgery. Collaboration Interested in being a guest contributor? Any suggestions and contributions will be promptly reviewed and added to the appropriate page/ subpage. The contributor will be noted on the website- you can choose if you want your name or Twitter handle or whatever other identification you would like (or none at all if you would like to be anonymous). Content currently under development. Note- this list is NOT all-inclusive. Database of clinical vignettes in key topics of trauma, critical care and emergency general surgery. Focused on more complex scenarios (ie not run-of-the-mill appendicitis)! Please check out the vignettes I currently have to get an idea of what I’m trying to create- and reach out with any suggestions or cases. Literature reviews - deep dives, high-yield articles, etc Procedural or skill tutorials (pre-peritoneal packing, using the ultrasound in critical care, reading a chest x-ray). Each tutorial is followed by a list of primary sources, encouraging readers to pull information from multiple references. If there is any particular procedure or skill that you would like to create a tutorial for, or something that is currently on the website that you would like to enhance (for example, more advanced ultrasound techniques or ventilator settings), please feel free to reach out with suggestions! There is a wide array of other content that you can add to as well. Note templates Recommendations on networking opportunities Recommendations on social media accounts to follow Educational resources (textbooks, journal articles, training courses, web based open access medical education) Please send me an email (form at the bottom of the page) or contact me on Twitter @doc_on_the_run if you have any questions or want to submit something.

Surgery trainee education. Trauma surgeon. Acute Care Surgery. FAQs Why did you make this website? Over these years of learning about the practice of surgery, I've also learned a lot about myself. I am not an expert, and I did not follow a typical pathway- but I have some knowledge and resources to share. As I transition into my new Acute Care Surgeon role after 17 years in training, I'm pausing to share my experience, tips for success, and random nuggets of wisdom. This will be a work in progress, and I look forward to seeing how it evolves. My goal is to share my experience and knowledge in the hopes of helping those who desire to follow this path. But why do we need another medical education website? There are so many good resources already... There are endless ways to explain clinical concepts- pictures, text, analogies, clinical cases, podcast discussions of cases or principles, review articles, etc. There are also different learning styles. When I was trying to grasp advanced ventilator management, I read basic critical care textbooks, a book dedicated solely to ventilator management, and various websites and journal articles. This website is another way to interact with the information. Hopefully you will understand some of the concepts in a new way that helps you remember and apply them in clinical scenarios. In addition, I have also tried to create a comprehensive collection of all the useful resources I know, like apps and open access medical education resources (websites, clinical guidelines, etc) in one place for trainees to What does Doc on the Run mean? The summer before my last year of medical school was the start of my running career. My focus was enjoying the outdoors, not pace or distance. During my residency, I met someone who helped me refine my running. I started timing myself, training, and racing. Within a year or two, I pushed through personal barriers to become a "runner." My first half marathon was on Thanksgiving in my third year of surgical residency. I am at the end of my formal training, I am now an Acute Care Surgeon. As a surgeon, there are numerous factors that I can't control. It's fast-paced, demanding, and dynamic. I enjoy the organized chaos and high-stakes cases. Running is key to my work-life balance. Unlike in the operating room or the trauma bay, I have control over most aspects of my runs- pace, distance, route, and thoughts. It's not chaotic- it's basically the polar opposite of my work. During the day, my mind is going a million miles an hour. When I run, everything becomes clearer- I can solve problems, mull over ideas, or process dilemmas. And perhaps the most concrete impact is the runner's high that I enjoy after finishing. I have continued to run 10Ks, 10 milers, and the occasional 5K or 15K. I have learned more about the science of running (HR training zones, different paces for tempo/ interval/ long runs/ short runs) and I've learned how to adapt training schedules to fit my life. Unfortunately, I have suffered my share of injuries, including most recently nerve impingement in my foot. While I may have scaled back, running will always be part of my identity. Did you really build this website yourself? Yes, I did. No, I didn't do all the intricate coding by myself. But I did design, format, and create the content. So are you a computer/ technology guru? Whatever I know about technology, I learned from my brother and from spending many hours researching problems online. While my parents might consider me an expert, I literally just search online to solve most issues. When I get to the end of the internet and still haven't found the solution, my next step is Apple tech support (obviously only if the problem is with my iPhone or Mac). What did you learn while making this website? - Formatting the working space on a website - URL redirect - Domains and subdomains - Search engine optimization (SEO) - Establishing custom domains - Which text/ background colors are easiest to read - Anchors If you weren't an Acute Care Surgeon, what would you do? I'd be a chef. I love cooking! Is there anything that is overwhelmingly gross in your job? I have had almost every body fluid on me- stool, urine, blood, etc. So very little grosses me out. But I can't stand oral or nasal secretions (aka saliva, slobber, snot, etc.).

< Back Ultrasound: Cardiac Exam Purpose: identify possible causes of hemodynamic instability, respiratory distress, assessment of volume status. Probe The phased array can be used for the entire exam. The curvilinear can also be used for the subxiphoid and IVC views. Views There are 4 basic views, including the parasternal long axis, parasternal short axis, the apical four chamber and the subcostal view. Additionally, the inferior vena cava can be visualized. Cardiac ultrasound is more challenging to learn than most other ultrasound studies, because probe usage (position, angle, rotation, translation, etc) have drastic impact on visualization. It’s necessary to understand what is shown in each view, so take time reviewing these so you can have a better appreciation for what you are seeing when you perform a study on a real patient. One recommendation, if it is difficult to visualize the heart, moving the patient into the lateral decubitus with their left side down can significantly improve visualization as the heart is closer to the chest wall in this position. For video and pictorial explanations of the views, please refer to these sites. Basic Cardiac Views, #1 Basic Cardiac Views, #2 Findings Gross abnormalities- decreased ventricular function, arrhythmias Profound hypovolemia Small hyperdynamic left ventricle with end-systolic collapse Inferior vena cava- assess volume status, either static measurement of diameter or calculation of collapsibility (>50% correlates with volume responsiveness). Respiratory variation (collapsibility/distensibility index). Takotsubo cardiomyopathy Akinesia of the apical and mid-ventricular segment, hypercontractile basal segments. Apical sparing (dilated). Acute cor pulmonale Respiratory disorder→ pulmonary hypertension→ right heart failure. Dilated right heart. Cardiac tamponade Effusion with end-diastolic collapse of the right atrium, effusion in front of the aorta Pulmonary embolism Free-floating thrombus in the right ventricle or pulmonary artery; right ventricular dilation/ systolic dysfunction; septal bowing into the left ventricle; dilated IVC without inspiratory collapse. Most sensitive/ specific indirect sign- right ventricular apical sparing (McConnell's sign). References Guidelines for Performing a Comprehensive Transthoracic Echocardiographic Examination in Adults: Recommendations from the American Society of Echocardiography Previous Next

< Back Cardiac Physiology Cardiovascular Physiology Oxygen Delivery Adequate cardiovascular function is vital to maintaining perfusion to the organs and tissues in the body. Perfusion drives oxygen delivery (O2) and removal of byproducts of cell metabolism (CO2). The amount of oxygen that is delivered (DO2) is a function of cardiac output (CO; the volume of blood ejected from the heart every minute) and the arterial oxygen content (amount of oxygen in the blood). Cardiac output is determined by the volume of blood the heart pumps out into the body with each heartbeat (stroke volume, SV) and the frequency of the heartbeat (heart rate, HR). Stroke volume depends on preload (blood volume returned to the heart), contractility (effectiveness of cardiac muscle activity), and afterload (pressure in the peripheral vasculature that the heart has to overcome to eject blood). Arterial oxygen content (CaO2) is the amount of O2 in the blood that is ejected from the heart. This is determined by dissolved O2 + O2 bound to hemoglobin. Hemoglobin carries O2, and the percentage of Hgb molecules that are saturated (bound) with O2 is determined by arterial blood gas (SaO2, arterial oxygen concentration) or pulse oximetry (SpO2, peripheral arterial oxygen concentration). Pulse oximetry is non-invasive and is a reliable surrogate (as long as SaO2 >90%). The O2 carrying capacity of one gram of hemoglobin is 1.38 (this is a constant in the equation). So this is the first part of the equation: the number of hemoglobin molecules x the % of those molecules that are saturated with O2 x how much O2 saturated hemoglobin can carry . The second part of the equation is the dissolved oxygen (partial pressure of arterial oxygen, PaO2, reported as mmHg). This value is multiplied by the constant 0.003, which is the mL of O2 dissolved per mmHg plasma. This number is infinitesimally small relative to the other half of the equation and it is typically ignored when determining oxygen concentration. This means that the significant modifiable factor in CaO2 is Hgb. Oxygen has to have something to bind to (Hgb) because dissolved oxygen has minimal oxygen-carrying capacity. Oxygen delivery (DO2)= CO x CaO2 Cardiac Output (CO)= heart rate (HR) x SV Stroke volume (SV)= the volume of blood ejected from the heart each heartbeat. Arterial oxygen concentration (CaO2)= [1.38 x Hgb x SaO2] + [PaO2 x 0.003] How can oxygen delivery be increased? One of the components of the equation has to be adjusted. Increase cardiac output. Increase SV- use of an inotropic agent (* medication that increases the strength of the heart contraction), ensure adequate preload (volume resuscitation). Increase HR- use of a chronotropic agent (* medication that increases heart rate). Increase arterial oxygen content Increase blood hemoglobin concentration *See pharmacology below Oxygen Consumption Oxygen consumption (VO2) is determined by how much oxygen the peripheral tissues extract and use. It is the difference between oxygen delivery (DO2) and oxygen return(ed) (SvO2). Oxygen consumption (VO2)= DO2 - SvO2. Oxygen consumption is calculated by subtracting SvO2 or ScVO2 from the amount of oxygen delivered. Venous oxygen saturation (SvO2 or ScVO2)- concentration of oxygen in the blood returning to the heart. Measured with a central venous catheter. *See below under CV monitoring for more details. Cardiovascular Monitoring There are several techniques for monitoring cardiovascular parameters, ranging from non-invasive to maximally invasive. Non-invasive methods include telemetry, pulse oximetry, and blood pressure monitoring. The benefit of these devices is their simplicity of use and interpretation. But these are error-prone, and regarding blood pressure, it doesn't provide continuous monitoring. For more info, see lecture entitled " Hemodynamics ". Arterial lines can be placed to provide continuous cardiac monitoring. The arterial waveform can indicate specific pathology (see Edwards Quick Guide to Cardiovascular Care ). In addition, an arterial line can report stroke volume variation. Stroke volume variation (SVV) is a surrogate of arterial pressure changes with inspiration/ expiration. If the change in pressure with respiratory cycles is >10-15%, it suggests the patient is fluid responsive, meaning they are likely to improve their preload (and cardiac output and blood pressure) with IV fluid administration. Central venous catheters can be placed to deliver intravenous medication as well as provide cardiac monitoring. A central venous catheter can measure the pressure of the blood returned to the right atrium (central venous pressure, CVP), which is a crude measurement of preload and right heart function. In addition, the oxygenation of the blood returning to the right heart (from the head and upper body) is reported as Central venous oxygenation saturation (ScVO2). ScVO2 reflects the balance between oxygen delivery and consumption. Arterial lines and central venous catheters are considered "minimally invasive". A pulmonary artery (PA) catheter is the most invasive device for cardiac monitoring. Similar to a central venous catheter, a PA catheter can determine the oxygenation of the blood returning to the right heart, which is the mixed venous oxygen saturation (SvO2). However, in contrast to the central venous catheter which is located in the superior vena cava (proximal to the right atria), this device is measuring blood oxygenation in the pulmonary artery (from the right ventricle), so it accounts for the blood from the entire body (unlike the ScVO2). Cardiac Pharmacology Vasoactive medications are frequently used in the ICU for the management of shock, heart failure, and other acute pathology. There are several key receptors, and understanding the function of each receptor is the key to using these different agents correctly. Receptors * α (alpha) 1- vasoconstriction * α2- inhibit norepinephrine release from presynaptic neurons * β (beta) 1- chronotrope (↑HR), inotrope (↑Ca in cardiac myocytes ↑contractility), dromotrope (↑cardiac impulse conduction velocity) * β2- vasodilation * Dopa 1- vasodilation * Dopa 2- neurotransmitter release Pharmacologic Agent Classification Each medication has a specific physiologic effect based on its particular mechanism of action. Agents may stimulate or inhibit receptors (see above) or alter the concentration of a key substance (cAMP, calcium, potassium, nitric oxide (NO)). Previous Next

11 < Back Board Examinations American Board of Surgery: General Surgery Boards Exam Prep Master the General Surgery Oral Boards by Dr Hassan Aziz . Dr Aziz reviews key surgical topics, including trauma, thoracic, pediatric, HPB, GI, breast cancer, endocrine, vascular. [Reference courtesy of Hassan Aziz, MD @Sharpknife_Aziz ] Surgical Education and Self-Assessment Program (SESAP). Resource for general surgeons- stay current with the latest surgical knowledge and prepare for examinations. American Board of Surgery: Surgical Critical Care Boards Exam Prep Evidence-Based Practice of Critical Care. 3rd edition, 2019. Reviews the literature regarding specific high yield critical care topics. Trauma, Critical Care, and Surgical Emergencies: A Case and Evidence-Based Textbook. 1st edition, 2010. 64 cases that review the basic principles of ACS. Previous Next

2 < Back Operating General Surgery Texts Chassin's Operative Strategy in General Surgery: An Expositive Atlas. 5th Edition, 2022. Zollinger's Atlas of Surgical Operations. 11th Edition, 2021. Operative Dictations in General and Vascular Surgery. 2012. Acute Care Surgery Texts Operative Techniques and Recent Advances in Acute Care and Emergency Surgery (Aseni). 1st edition, 2019. Surgical Decision Making in Acute Care Surgery. Atlas of Trauma/Emergency Surgical Techniques. Top Knife (Mattox). 1st edition, 2004. High yield of trauma operative management. Back to the basics. Atlas of Surgical Techniques in Trauma (Demetriades). 2nd edition, 2020. Anatomic Exposures in Vascular Surgery (Wind). 3rd edition, 2013. Key anatomic exposures for less commonly encountered injury patterns. Recommended by Dr. Feliciano at AAST 2020 Conference. Videos Surgical Stabilization of Rib Fractures and Cryoablation. Collection of videos of different surgical approaches. WebSurg. Free access to expert videos of minimally invasive surgery. Highly recommend. The Toronto Video Atlas of Surgery. Free access to expert videos of GI operative procedures. [Reference courtesy of EJS @ElliotJScottMD] Difficult Cholecystectomy: A learning module for laparoscopic cholecystectomy How to Tie Knots Like a Heart Surgeon How to Secure Chest Tubes (Soweto Tie) Previous Next