< 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

Ratios < Back Kitchen Hacks #5 Ratios Cooking with Ratios Bread 5:3 flour to water- for example, 300g flour and 180g water. With this ratio in your arsenal, the world of bread is at your fingertips. You can explore different flours, hydrations, and additions like seeds and nuts from here. Salt: Around 2% of the flour weight (e.g. 6g salt for 300g flour) Yeast: Around 1% of the flour weight (e.g. 3g yeast for 300g flour) Muffin/Quick Breads 2:2:1:1 flour:liquid:eggs:fat Baker Move: Baking times and temps can vary based on something as simple as the humidity in the air. Pros test the doneness of muffins, quick breads and cakes by simply inserting a toothpick. If it comes out clean, they are ready to cool. Biscuit 3:2:1 flour:liquid:fat Baker Move: Pros always scoop flour, sugar or other dry ingredient into a measuring cup, then use the back of a knife or other straight edge to level it off. Vinaigrette 3:1 oil to vinegar. Add herbs, garlic, or mustard to elevate your dressing Cookies 3:2:1 flour:butter:sugar Other ingredients like eggs, baking powder, and flavourings can be added, but the core 3:2:1 ratio for the main dry, fat, and sweet components is the foundation. Baker Move: Using a dough scoop (like a small ice cream scoop) to portion equal-size cookies adds a professional touch to your finished cookie plate. Pound Cake 1:1:1:1 flour: egg: fat (unsalted butter): sugar Baker Move: Pull your butter and eggs out of the fridge a couple of hours before you're ready to bake. Room-temperature butter is better for creaming, and you'll want the eggs at the same temperature to prevent them from seizing. Pancakes 2 parts flour: 2 parts liquid: 1 part eggs: 1/2-part fat Baker Move: Slowly incorporate the liquid into the dry ingredients while whisking constantly for effortless, lump-free pancake batter. Meringue 2 parts sugar: 1 part egg whites or 1 part sugar: 1 part egg yolks Baker Move: Avoid cracks in your perfectly piped meringues by keeping your oven door closed while they dry out. Yep, that means no peeking. Pie Dough 3:2:1 flour:butter:water Baker Move: Soggy-bottomed pie crusts, be gone! Pros know to par-bake their crusts for fresh fillings. Fritter 2:2:1 flour:liquid:egg Baker Move: The key to a crispy fritter is to never crowd the pan. Drop too many in the frying oil at once and the temperature will plummet, producing a greasy, mushy fritter. Custard 2:1 eggs:liquid Baker Move: Once you have that ratio down, remember to strain your cooked custard through a fine mesh sieve to remove any lumps. Crepes 1/2:1:1 flour:liquid:egg Baker Move: Crepe batter needs time to set up, preferably overnight in the fridge. Links Cooking with Ratios Food Network Previous Next

< Back Unusual Case of Peritonitis A 23-year-old male presents to the ED with several days of abdominal pain. He is otherwise healthy and denies any other symptoms. On exam, he has diffuse peritonitis, but no other obvious findings. He is tachycardic with a heart rate in the 110s-120s. His blood pressure is 100s/60s. No significant medical or surgical history. No remarkable events recently. He had plain films of his chest and abdomen. Plain film of the chest and upper abdomen What's going on? Differential diagnosis? Perforated hollow viscus- gastric or duodenal ulcer, bowel obstruction leading to perforation, procedural complication (EGD, ERCP). On further questioning, the patient endorses a recent soccer game during which he blocked a goal and was hit in the stomach. Unsure if it was the soccer ball or a kick to the stomach. He then had a CT of his abdomen and pelvis. CT of the abdomen and pelvis, representative slices What's going on? Diagnosis? Intervention? Free air (pneumoperitoneum) and free fluid are consistent with a perforated hollow viscus. No clear source on the CT. This requires abdominal exploration. We proceeded with exploratory laparotomy. Found liters of succus. There was a single perforation of the small bowel that was resected and anastomosis was performed. The abdomen was closed and a drain was placed. Intraoperative Findings Management of Peritonitis from Perforated Hollow Viscus The hollow viscus refers to the gastrointestinal tract from the esophagus to the rectum. Pain associated with hollow viscus perforation is classically acute onset, constant, severe, and worse with movement. The peritoneal lining of the abdomen becomes inflamed in reaction to the leaking enteric contents. This is a surgical emergency. The diagnosis can be made with the visualization of pneumoperitoneum on an upright chest x-ray (lucency under the diaphragm). A patient with peritonitis and free air requires surgical exploration. A CT scan can help identify the underlying pathology, but is not mandatory and should not delay operative intervention. Non-operative management is reserved for the patient with a sealed perforation (example- retroperitoneal duodenum) or a patient who is a prohibitively high-risk operative candidate (example- patient on palliative or hospice care). Cultural differences Not all cultures have adopted the practice of Western medicine. In some cultures, people still seek advice and medical care from traditional healers. Unfortunately, this can delay treatment if a patient requires operative intervention. Some of the treatments provided by traditional healers can also lead to further injury. This patient with a small bowel injury was seen by a traditional healer several times before he was finally brought to the hospital. The marks on his skin are the result of a practice of cutting the skin to heal the cause of his abdominal pain. Another patient was brought to the hospital for a severe infection of his genitalia. By the time he came to the hospital, his infection was so extensive that he required a debridement of a large portion of the skin in his perineum. He had been seeing a healer who was treating him with a topical solution that had essentially burned his skin, so in addition to the underlying infection, he had severe tissue damage. Previous 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 Appendicitis What is appendicitis? The appendix is a small worm-like structure that hangs from where the small and large bowel connect in your right lower abdomen. It can become inflamed and cause pain. What does surgery entail? What are the risks of the procedure? The surgery to remove your appendix involves using a camera and thin instruments. We typically make 3 incisions- one at your belly button, one right above your pubic bone and one in the left lower abdomen. We divide the appendix with a stapler and remove it. You’ll have a foley in your bladder to help get your bladder out of the way because one of the ports is placed right over the bladder. The folly goes in after you go to sleep and is removed before you wake up. It might burn the first time you pee after surgery. There is a risk of infection following an appendectomy. Bacteria live in the appendix and when we divide it, the bacteria can fall out and form an abscess. This risk is higher if your appendix is ruptured at the time of surgery. This typically presents very similar to appendicitis, because it’s an infection in the same part of your abdomen. Most of the time that can be managed without surgery. We can have our radiology colleagues place a drain into the abscess cavity. What can I expect post-operatively? You will have several small incisions from the laparoscopic port sites. They will have absorbable sutures, nothing that needs to be removed. You will have glue or gauze and paper tape on the incisions. The glue will peel off on its own in 10-14 days. If you have gauze, you can remove this in two days and shower like normal. You will have paper tape strips on the incision, and these will peel off on their own. You are at risk for a hernia through the small incisions, so avoid heavy lifting for 4 weeks after surgery. You may take acetaminophen (Tylenol) and ibuprofen (Motrin) as needed for pain. These can be taken at the same time. Take the narcotic pain medication if your pain is severe despite the acetaminophen and ibuprofen. After the few first days, you should work on decreasing the number of narcotics that you are taking. What can I eat after surgery? There are no specific dietary restrictions. However, if you eat a fatty meal, it may cause loose stool (diarrhea) until your body adjusts to not having your gallbladder, which previously stored the chemicals used to digest fatty food. This is seen in about 10% of patients and usually resolves. If it lasts more than a few weeks, there are medication options to treat this. What should I be worried about after surgery? If you have fever >101 F, severe nausea/ vomiting, inability to tolerate liquids, severe abdominal pain, increasing redness, or drainage from your incisions. Patient Information from Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Appendix Removal (Appendectomy) Surgery American College of Surgeons Appendectomy: Surgical Removal of the Appendix Previous Next

Caring for soldiers in the deployed environment Austere Damage Control Surgery < Back Caring for soldiers in the deployed environment “Our general attitude around here is that we want to play par surgery. Par is a live patient.” Several years ago, when I was preparing to apply for trauma fellowship, someone called me a meatball surgeon. I thought it was a lame nickname that meant our job was mindlessly easy. For the first time ever, I recently Googled meatball surgery. The term "meatball surgery" was used to describe the damage control interventions performed in MASH. Yes, I am proud to say I am a meatball surgeon for our soldiers. Telling me I save lives is a compliment…not an insult. Meatball Surgery Military surgeons are frequently deployed to far forward environments to perform damage control surgery- stopping bleeding, stopping gross spillage of bowel contents, stenting vascular injuries, etc. This allows the patient to be evacuated to the next level of care. The goal is NOT definitive repair of injuries. All general surgeons deploy in this role- so maintaining trauma operative skills and the skill of "thinking like a trauma surgeon" is crucial. This is being increasingly provided between deployments with skills labs and military civilian partnerships. There is still a significant gap between recommended case volume and actual case volume. Recently, the suggestion to train non-surgeons to do “just a bit of damage control surgery" in the deployed environment has been proposed in several forums, including on social media. Short version: “You can’t convince me that pelvic packing, laparotomy, vascular control, thoracotomies are difficult.” Why is this a problem? As mentioned, its hard enough to train our general surgeons well-trained to perform in this environment. It would take significant changes in our current training rhythm to get Pas and non-surgeons adequately proficient to provide this skillset. It is NOT easy being a trauma surgeon. A lot of surgery residents are familiar with the oft repeated quote, "you can teach a monkey to operate". It's not meant to insult trainees and compare them to monkeys. It's meant to explain that the difficult skill of being a surgeon is the judgment to decide who needs surgery, what surgery is needed and how to anticipate the next step. There are many algorithms in surgery. They are excellent guides to optimal patient care. But they all have the same caveat (although some might not state it as explicitly)- they are not to be used in isolation, but instead in the setting of sound clinical judgment. To gain this expertise, surgeons endure 4 years of undergraduate education, 4 years in medical school, 5-7 years of surgical residency, and 1-2 years of fellowship. And even after I spent all this time training, I’m still not done learning this art. If you say these are "not difficult” procedures, I encourage you to complete a general surgery followed by a trauma fellowship. The military actually does need more trained trauma surgeons. But no, I’m not interested in training a non-surgeon to do “just a little bit” of trauma surgery. I can't imagine any trauma surgeon who would be willing to teach a watered down version of our skill to a non-surgeon and sign off that they’re qualified to care for our soldiers. Please don't insult our expertise. I would never presume to be an expert in another persons specialty. This would be similar to suggesting that I can be easily trained to be special forces. Anyone can be taught to shoot a weapon, evade the enemy, decide the best tactical approach, etc. You may say that’s an exaggeration. But it’s the absolute truth. A field surgeon is NOT a surgeon. A brigade surgeon is NOT a surgeon. A flight surgeon is NOT a surgeon. A division surgeon is NOT a surgeon. A battalion surgeon is NOT a surgeon. The Surgeon General is NOT a surgeon. Previous Next