< Back Vent Mgmt #2: Modes Mandatory Breaths Volume control (volume limited)- set TV and flow, pressure and inspiratory time are the dependent variables. Pressure control (pressure limited)- set inspiratory pressure and inspiratory time, volume and flow are the dependent variables. What is the downside of VC and PC? You can only control one parameter, and the dependent variable varies based on the patient's lung mechanics. For a patient on VC, if their lungs become less compliant, delivering the same tidal volume will generate higher pressure, increasing the risk of barotrauma. For a patient on PC, if their lungs become less compliant, the target pressure will be reached at a lower volume, so there is a risk of decreased ventilation (↑PaCO2). Pressure-regulated volume control (PRVC) is a hybrid mode that attempts to overcome this limitation. The target volume is delivered at the lowest possible inspiratory pressure by assessing the delivered tidal volume at the inspiratory pressure during each breath. What about inverse ratio (IR, IRV-PC) ? Increasing the inspiratory time relative to expiratory time increases mean airway pressure. This can be accomplished with pressure-controlled modes, where inspiratory time can be prolonged (normal ratio 1:2, IRV is when inspiratory time is greater than expiratory time). As discussed, MAP affects the surface available for oxygen exchange. This is why IR can be used to optimize oxygenation. Mandatory and Spontaneous Breaths Synchronized intermittent mandatory ventilation (SIMV)- a variation on VC or PC. The machine delivers mandatory breaths, but the patient can also control spontaneous breaths in between the mandatory breaths. Spontaneous Breaths Pressure support- spontaneous mode, the patient initiates breath, the ventilator provides support to overcome the resistance of breathing through the endotracheal tube, flow is adjusted to maintain the inspiratory pressure. The support is terminated when the flow decreases to <25% of peak flow. The patient controls duration and volume. *This is also a setting that can be adjusted in SIMV for assisting spontaneous breaths between ventilator breaths. Airway Pressure Release Ventilation (APRV)- invasive form of ventilation with BiPAP. The patient breaths spontaneously, alternating between a sustained time (time-high) at a set pressure (pressure-high) with a very brief release (time-low) of pressure (pressure low) to allow expiration. The goal is to maintain a higher MAP to optimize oxygenation. Previous Next

< Back Pneumonia...pending Pneumonia Previous Next

< Back Nutrition...pending Nutrition Previous Next

< Back ACS Fellowship Is Acute Care Surgery the right specialty for you? If you are considering a career in Acute Care Surgery, it's important to explore the profession thoroughly before making any decisions. While there are numerous resources available to help you make an informed decision, one of the most valuable resources is speaking with surgeons who currently practice in this field. Experiences can vary widely at different hospitals, so don’t rely on just one opinion. Acute Care Surgery is a challenging specialty that will test you in ways you may never have imagined. It requires a high level of expertise in multiple clinical disciplines. As a surgical critical care fellow, you will face many challenges, such as long working hours, unpredictable workloads managing a mixture of high acuity critically-ill and injured patients, high patient mortality rates, and frequent exposure to severely injured patients. These challenges are not unique to Acute Care Surgery, but they are particularly profound in this field. One of the most significant challenges of this specialty is the emotional toll that it can take on practitioners. Managing patients in the ICU requires a high degree of empathy and compassion, and you will be required to deliver bad news to families and help them navigate difficult decision-making processes. It can be incredibly challenging to witness the suffering of patients and their loved ones, and it's essential to have a good support system in place to help you manage the emotional demands of the job. Despite these challenges, many surgeons find Acute Care Surgery to be an incredibly rewarding profession. Through their work, they have the opportunity to make a significant impact on the lives of their patients and their families. They develop strong relationships with patients and their loved ones, and they have the opportunity to witness the resilience of the human spirit in the face of adversity. If you are considering a career in Acute Care Surgery, it's essential to be well-prepared for the challenges that you will face. Seek out opportunities to speak with surgeons who practice in this field and learn from their experiences. Develop a strong support system that can help you manage the emotional demands of the job, and focus on developing the critical skills that are required to be successful in this challenging and rewarding specialty. With the right preparation and mindset, you can make a significant difference in the lives of your patients and their families as an Acute Care Surgeon. How do I become an Acute Care Surgery fellow? While there are many one-year surgical critical care and two-year trauma/surgical critical care fellowships available, it's important to note that as of 5 October 2020, there were only 28 AAST-approved Acute Care Surgery Fellowships. The application process for these fellowships is centralized through SAFAS . This means that you will need to enter standard personal information, test scores, and personal statements. Additionally, you will need to obtain several letters of recommendation. After you submit your application, programs will contact you if they are interested in offering you an interview. When applying for these fellowships, it's important to cast a wide net and not limit yourself to just a few programs. This may seem daunting if you are applying during your final year of residency, and you are likely already very busy with patient care, managing your team, preparing for board examinations and completing the documentation required for residency completion. Before the COVID pandemic, fellowship interviews were in-person. This was expensive and time-consuming. Virtual interviews may ease this burden, but it’s still a time-consuming process. While you may have a short list of your top choices, I would encourage you to consider a broader range of options. Some programs have online resources that can provide valuable information about the program's strengths and focus areas. When selecting programs, consider your own priorities. Are you looking for a strong critical care focus or a high volume of operative trauma cases? Do you have specific research goals? Fellowship is a short and intense period of focused training to allow you to develop the clinical knowledge and procedural skillset to thrive in this field, so be prepared to commit yourself fully to this opportunity. It's important to note that no program will be a perfect fit for everyone. However, if you approach the application process with an open mind and invest time in your search, you can find a fellowship that sets you on a path towards a fulfilling career in acute care surgery. Helpful Websites AAST ACS Fellowship Applicants . Website with more detailed information about what an Acute Care Surgery Fellowship entails. Approved Acute Care Surgery Fellowships . American Board of Surgery . National organization for board certification in General Surgery, as well as subspecialties including Vascular Surgery, Pediatric Surgery, Surgical Critical Care, Hand Surgery, Surgical Oncology, and Hospice and Palliative Medicine. This is one example of the experience of an ACS fellow at a Level 1 trauma center with a well-organized fellowship program and a well-developed research team. Please refer to " How to get involved " for more information. Clinical Work 12 months of critical care based rotations 8 months of trauma/ surgical critical care (TICU/ SICU) 1 month of cardiac surgical critical care 1 month of medical critical care (MICU) 1 month of Emergency Department Ultrasound training 2 weeks with Nephrology 2 weeks of Research 12 months of surgical rotations 6 months of trauma 3 months of emergency general surgery (EGS) 1 month of transplant surgery 1 month of vascular surgery 1 month of cardiothoracic surgery Research and Publications Two IRB approved research protocols. Lead author on 4 submitted manuscripts. 2 peer-reviewed publications (one as first author). Accepted literature review. Published personal essay. Sub-Investigator on Chest Tube Insertion Trial Author of a book chapter on thoracic trauma management in the ICU Presentations Presented basic science research at AAST Conference Presented process improvement project at department level research symposium Presented a personal essay presented at the EAST conference Nine formal department level lectures. Multiple ICU team lectures. Educational Opportunities Attended operative rib fixation training course Attended training course on IVC filter placement Attended two AAST conferences and one EAST conference Attended critical care/ trauma outcomes committee meetings and trauma morbidity and mortality conferences Attended quality improvement symposium Involvement with local and state trauma advisory committee meetings Previous Next

< Back Who Is Our Patient Population? We take care of critically ill and injured patients. Here are just a few examples of the different patient scenarios we manage. We are available 24 hours a day, 7 days a week. Therefore, we often receive consults for various other surgical disease processes outside of what is listed here. Trauma Penetrating wounds from gunshot wounds, stabs, or assaults from any material that breaks the skin and causes bleeding or significant tissue damage Blunt injuries from falls (roof, ladders, etc.), motor vehicle accidents, bicycle accidents, pedestrians struck by vehicles. Non-accidental injuries (abuse, inter-personal violence) Surgical Critical Care Critically ill trauma or emergency general surgery patients. Patients undergoing complex or high-risk surgical procedures or requiring intensive care unit (ICU) admission. Complications from procedural interventions. Intra-abdominal catastrophes. Airway emergencies- patients who are unable to be intubated and require a surgical airway. Emergency General Surgery Appendicitis, Cholecystitis, Diverticulitis. Bowel ischemia or bowel obstruction. Soft tissue infection- necrotizing soft tissue infection. Surgical airway or enteral access- tracheostomy for ventilator dependency and percutaneous endoscopic gastrostomy (PEG). 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

Confessions of an ICU Physician with a terrible memory Accessing the Right Information < Back Confessions of an ICU Physician with a terrible memory Training in medicine starts with textbook learning. But the art of caring for patients can’t be learned in a textbook. Higher-order thinking is essential to understand the interaction between multiple conflicting disease processes, identify nuisances of atypical presentations and find solutions for clinical conundrums. As the field of medicine grows exponentially, the volume of information is too much for one person to keep track of. I find that understanding clinical concepts is much easier than rote memorization of pharmaceutical brand names with their associated generic name, recalling the dose of a paralytic, or identifying the ideal antibiotic for a multi-drug resistant bacteria. After several years of learning and studying mechanical ventilation and how it interacts with and affects a patient's respiratory physiology, I now understand the principles of how to optimize oxygenation and ventilation. As an ICU physician, I can't re-read the basic textbook of mechanical ventilation every time I care for a patient with respiratory failure. I must be able to make decisions relatively quickly and must be able to explain my rationale to residents and bedside nurses while we are working to manage a patient with severe lung disease. But I can pause to look up the recommended dosing of a medication for a patient on dialysis or identify the best anti-microbial for a particular bacteria or fungi. What do I do about important information that I need immediate access to but that doesn't reside in the forefront of my mind? Smartphones, with access to websites and applications , have revolutionized our ability to bring evidence-based medicine to the bedside. Clinical practice guidelines can be accessed on society websites. Deployed Medicine is a resource that provides access to Tactical Combat Casualty Care and Joint Trauma System Clinical Practice Guidelines. There are apps for a wide number of clinical programs that were initially web-based, such as UpToDate. In addition to the resources that are openly available to the public, I have created a database of personal high-yield references. Medication dose ranges, CPGs for our trauma center, AAST Injury Scales, sedation/ pain scores, TEG parameters, and a wide variety of other information that I refer to on a relatively routine basis are now in the palm of my hand. I use the Trello app. I created a dedicated workspace with a group of lists (titles such as trauma, medication, ICU, etc) which each contain multiple individual cards (titles such as A-F bundle, CAM-ICU/ RASS/ CPOT, TEG). I'm not saying you have to use this. But I highly recommend finding a tool that works for you. TL;DR • Take the time to understand processes and concepts- learn one physiology concept from each pt • Have an external tool for storing “rote memorization” facts that you can readily access Previous Next

6 Note Templates Trauma Admit Note Template .pdf Download PDF • 31KB ICU Progress Note Template .pdf Download PDF • 21KB ICU Rounds Sheets .pdf Download PDF • 46KB Extubation Note .pdf Download PDF • 30KB

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

< Back Pneumothorax American Thoracic Society- Patient Education | INFORMATION SERIES What is a Spontaneous Pneumothorax? Tube Thoracostomy (Chest Tube) You have a pneumothorax. This happens when your lung collapses and there is air in your chest. This can be spontaneous but is also frequently secondary to trauma. Imagine your lung is a balloon. When there is a hole in the balloon (penetrating wound to the chest, rib fracture, etc), the balloon collapses. When you breath in, the air moves from your airway, into the balloon and then out into your chest, the space around your lung. A chest tube is placed to evacuate the air from your chest and allow your lung (the balloon) to reexpand. As long as the hole in the lung is small, removing the air is generally all that is required. This is because when the lung is stuck back up to the inside of your chest, air stops leaking into the space around your lung. Surgery is infrequently required for management of a pneumothorax. This occurs when the lung fails to reinflate despite placement of a chest tube. It can also be required if there is an “air leak”. An air leak is the result of the ongoing leakage of air from the lung into the chest. The air that moves into the chest continues to be evacuated into the chest tube, and this is seen as bubbles in one window of the chest tube drainage canister. Spontaneous pneumothorax is often due to apical blebs, which are small areas at the lung of your lung that have thinned out and can rupture, with a similar results as a traumatic hole in the balloon that is the lung. Previous Next

How to play nice in the sand box...and why it matters Consults < Back How to play nice in the sand box...and why it matters The department of Acute Care Surgery and Emergency Medicine frequently interact to discuss consults. Unfortunately, several factors predispose to an adversarial relationship between the ER provider and the consultant.(1) I won't pretend that I didn't contribute to some of the negative interactions I've had while responding to consults. However, I'm grateful that my years of experience have provided me with insight and perspective that reframed my thoughts about the consultation process. What are the different types of consults? #1 The patient requires something that is beyond the scope of practice of the emergency provider. This includes everything from hospital admission, surgical or procedural intervention (appendectomy, stop the bleeding from a penetrating neck wound, cardiac catheterization), or a plan for close follow-up. How to Respond? This is why we chose our specialty, and our business is patient care. If a consultant is not responsive, it might be because they are caring for more urgent clinical issues. It's also possible that they are a generally unpleasant person, and it has no relation to the nature of the consult..some people can be difficult regardless of the scenario. Admittedly, it might also be 2 am, and they just fell back asleep after their last page. As much as I hate to admit, it's harder to be pleasant on the phone when you're absolutely exhausted. #2 The unclear diagnosis. The patient is presenting with a complex issue, or the diagnosis may be outside the provider's experience. This could be the first time they encounter a particular clinical scenario or an unusual presentation of a common diagnosis. How to Respond? Depends on the scenario. If that patient requires emergent assistance, prioritize their needs. If no emergent need, but further workup is needed, provide whatever recommendations you can regarding the next steps of the diagnostic workup. If the patient's case falls under your specialty, refer back to #1. #3 The emergency room provider doesn't know who the appropriate consultant is, or they have had no luck reaching them. How to Respond? It's easy to brush off a call when the primary provider called the wrong service. This might occur if the provider cannot reach a particular specialist, and you are the next best option (example- plastic surgeon doesn't respond for a consult on a patient with a wound complication). Please, if you know how to reach that provider, lend a hand. Or, if they call the wrong service, take the time to give a little guidance about whom they should have called. They aren't trying to waste your time- they are likely also busy, and calling multiple consultants is not the best way to spend their time either. Whatever assistance you can provide is best for the patient. #4 The controversial consult. In my experience, during years of working with surgeons and emergency physicians, probably one of the most contentious consultations is the consultation for something that the consultant considers inappropriately simple or unnecessary. The surgeon may think that the issue is trivial or the need is non-existent and feel that the provider should be capable of resolving the issue without calling a surgeon. This disconnect might be the key patient interaction that can set the tone for the relationship between departments. How to Respond? First, and most importantly, please don't be dismissive when someone calls you for a consult. If you are receiving a call, it's because the person on the other end of the phone (and therefore the patient they are caring for) needs your help. Surgeons, along with other specialists, have extensive specific expertise, so it's easy to lose perspective and presume that the knowledge in our head is universal. It's become almost intuitive in our minds, so we might forget that the primary provider does NOT have the same specialization. We each chose our respective specialties, and our training and biases are quite divergent. It is unreasonable to expect ER physicians to share the same depth of knowledge in each of the many specialties, just as each of the specialists would not have the same ability to deftly juggle the wide array of clinical scenarios managed in the ER. I remember the plastic surgeon who showed me how to do a scar revision on a young woman's face. He spent his career training and practicing to perform plastic surgery. It was simple in his hands, but that doesn't mean the woman would have a similar outcome if the needle driver was in my hand. Please, think of the patient's best interest. Yes, the primary provider may be "an idiot" or "lazy" or whatever. But consider the other possibilities. I prefer to give my colleagues the benefit of the doubt and avoid automatically assuming incompetence. Regardless of the underlying issue, whether it's a flaw of the provider or its truly beyond their capability, the patient needs someone to take care of them. Do the right thing for the patient- in the end, that's what matters. 1. Koo A, Bothwell J. Tips for Working with Consultants. ACEP Now. Nov 2017. Previous Next

< Back Postoperative hypotension A 35-year-old male is in the ICU following emergency surgery for a small bowel obstruction. On arrival to the ICU, he has the following vital signs: HR 115, BP 85/40, SpO2 98. He underwent a 4-hour open lysis of adhesions. He received 2L of crystalloid and made 50 mL of dark urine, and did not require any medication to improve his blood pressure. He remains intubated and sedated. What is the differential for his hypotension? Hypovolemia- under-resuscitation relative to the insensible losses from open abdomen and likely preoperative dehydration Sepsis- bacteremia from gut translocation from small bowel obstruction, pneumonia from aspiration due to obstruction Tamponade, tension pneumothorax- did he have any intra-vascular devices placed in the OR? Pulmonary embolism- lengthy surgery, did he have appropriate mechanical prophylaxis? Cardiomyopathy The surgical team reports that he has not been tolerating a diet, or even liquids, for the previous 3 days. He received perioperative ertapenem for surgical infection prophylaxis. There was no evidence of aspiration during intubation and his admission CXR was unremarkable. He had a right internal jugular central line placed intra-operatively. He had no issues with oxygenation/ ventilation or high airway pressures intra-operatively. How can you diagnose shock and differentiate between the different potential etiologies? Physical exam- evaluation of skin turgor/ color/ temperature and mucous membranes, evaluation of fluid status (open wounds, nasogastric tube output, passive leg raise), examination of urine quality, auscultation of heart/ lungs Labs- cultures, complete blood count, lactate, liver function tests, BUN/Cr Ultrasound- gross evaluation of heart function, lung sliding to rule out pneumothorax, volume and collapsibility of the inferior vena cava Test for fluid responsiveness- based on stroke volume variation (SVV, see below), or response to passive leg raise or a fluid challenge. On exam, he is tachycardic without murmurs, lungs have equal air movement bilaterally. His nasogastric tube remains on suction with ongoing high output of gastric contents. On ultrasound, he has bilateral lung sliding. His cardiac contractility looks grossly preserved. He has normal oxygenation. His inferior vena cava is collapsible. He has a known source of infection (positive blood cultures), leukocytosis, elevated lactate, high fluid losses with evidence of fluid responsiveness. Shock: Undifferentiated Hypotension Hypotension ≠ shock. So what is shock? Inadequate perfusion to maintain end-organ function Pathophysiology: effective perfusion requires adequate cardiac output (CO). CO is the volume of blood that the heart pumps each minute, and it depends on stroke volume (SV; the volume of blood ejected with each heartbeat) and heart rate (HR; the number of heartbeats per minute). SV depends on preload (intra-vascular volume returning to the heart), myocardial contractility, and afterload (systemic vascular resistance). Shock is a disruption of preload, contractility, and/ or afterload. Signs of shock= signs of end-organ hypoperfusion Altered mental status (brain) Decreased urine output (kidney) Change in color/ temperature of extremities (skin) Abnormal liver function tests (liver) Ileus (gastrointestinal tract) Diagnosis of shock + tools for monitoring response to treatment Elevated lactate (global hypoperfusion) Ultrasound- evaluate cardiac function, evaluated IVC to assess volume status Minimally invasive cardiac monitoring (central line or arterial line)- CVP and SVV to assess volume status Invasive cardiac monitoring (pulmonary artery catheter)- cardiac output, ScVO2 (central venous oxygen saturation) Four types of shock Shock is typically categorized as hypovolemic, obstructive, cardiogenic or distributive. However, in order to link the specific category with the associated pathophysiology, I have described each state as it relates to maintaining cardiac output, as described above. Decreased preload: hypovolemic shock- low circulating blood volume→ decreased blood volume returning to the heart. Etiologies: bleeding, inadequate fluid replacement/ maintenance, high output from nasogastric tube or ostomy, insensible losses that aren't appropriately replaced (burn patients, large open wounds). Decreased preload: obstructive shock- disease process that impedes venous return to the heart (tamponade, tension pneumothorax, pulmonary embolism). Decreased contractility: cardiogenic shock- disturbance of the intrinsic function of the heart. Etiologies: heart failure, arrhythmias, valvular insufficiency, or decompensated valvular stenosis. Decreased afterload: distributive shock- dilated peripheral vasculature, sometimes known as vasoplegia. Etiologies: sepsis, anaphylaxis, neurogenic following spinal cord injury (NOTE- this is NOT the same as spinal shock), burns, trauma, pancreatitis. Neurogenic- hypotension with concurrent bradycardia. Vasoplegia is a term used to describe pathologically low systemic vascular resistance- this can be associated with post-cardiac bypass or any of the other causes mentioned here. Management of shock Treat underlying cause (see below). Restore adequate intravascular volume (aka preload). This is part of the initial treatment of hypovolemic shock, obstructive shock, and distributive shock. Fluids in the management of cardiogenic shock depend on the primary cardiac pathology. Treat hypotension/ decreased cardiac output that persists despite fluid resuscitation and treatment of the underlying cause. Septic shock- norepinephrine is the first line vasoactive medication. Monitor end-points of resuscitation (see above, Diagnosis of shock + tools for monitoring response to treatment ) Supportive care- nutrition, respiratory support, venous thromboembolism, etc. Specific Treatments Based on Etiology Hypovolemia from hemorrhage- transfusion, stop the bleeding Hypovolemia from fluid losses- replace fluid via enteral or intravenous route, as appropriate Sepsis- antibiotics, control source of infection (appendectomy, drain placement, etc). Tamponade- drainage of pericardial fluid (pericardiocentesis, pericardial window) Tension pneumothorax- release of tension physiology (needle decompression or finger thoracostomy) Cardiogenic- management of primary cardiac pathology, whether that entails treating acutely decompensated heart failure, resolving acute symptomatic arrhythmias, etc. Previous Next