< Back Thoracoabdominal Wound A 32-year-old male is brought to the ER after sustaining a gunshot wound to the right thoraco-abdomen. He is hemodynamically stable. What are the initial steps of evaluation and management? Imaging? Secondary survey to rule out other wounds. FAST exam. CXR. What injuries must be considered with these wounds and imaging patterns? Chest (heart, lungs, etc.), abdomen (solid organs or hollow viscus), and diaphragm. He underwent exploratory laparotomy. He was found to have a right diaphragm defect, which was repaired primarily. There was a transhepatic GSW and hepatorrhaphy was performed with chromic suture. A blast injury to the anterior gastro-esophageal junction was buttressed with an anterior Dor fundoplication. Management of Thoracoabdominal Wounds The thoraco-abdomen is between the nipples and the costal margin. Organs in the chest and abdomen can be injured, and the diaphragm is also at risk. Liver Trauma Management depends on how it is diagnosed and the patient's hemodynamic stability and physical exam. Diagnosed pre-operatively on CT scan + no concern for the need for operative intervention for concurrent injury→ non-operative management if the patient is hemodynamically stable without peritonitis. Embolization should be considered in adults with active arterial extravasation on CT. Operative intervention is indicated for hemodynamic instability, ongoing transfusion requirement, and/ or change in the abdominal exam. Diagnosed intra-operatively→ management depends on the severity and presence of bleeding, presence of concomitant injuries. Hemorrhage control is the immediate concern. Manual pressure and packing (sandwich lap pads above and below) first. If this is ineffective, use the Pringle maneuver (hepatic inflow control)→ if bleeding stops, it was either hepatic artery or portal venous in origin. If bleeding continues, hepatic vein or IVC are likely injured. Minimal bleeding can be controlled with cautery, hemostatic agents, omental packing, or argon beam coagulation. Moderate bleeding from a laceration from often be controlled with suture hepatorrhaphy. More significant bleeding may require non-anatomic resection or vessel ligation. Topical hemostatic agents Absorbable hemostatics Oxidized regenerated cellulose- Surgicel, Surgicel Fibrillar (sheet), Surgicel NuKnit Polysaccharide- Arista Porcine collagen (gelatin matrix)- sponge, film, or powder. Brands- Gelfoam, Gelfilm, Surgifoam. Bovine collagen (microfibrillar)- sponge, sheet, powder. Brands- Avitene, Ultrafoam. Sealants with thrombin or fibrin Thrombin, reconstituted (Recothrom) Thrombin + collagen + chondroitin sulfate (Hemoblast) Thrombin + bovine gelatin (Floseal) Thrombin + porcine gelatin (Surgiflo) Thrombin + fibrinogen + aprotinin + plasminogen (Tisseel) Thrombin + fibrinogen + albumin (Evicel) QuikClot- kaolin HemCon- chitosan If there is a trans-hepatic wound, tamponade can be created by threading a red rubber catheter through a Penrose drain, placing this into the wound, and then filling the Penrose with saline. Stabina S, Kaminskis A, Pupelis G. Start of Polytrauma Management in University Hospital: First Experience with Liver Trauma. Acta Chirurgica Latviensis. 2014;14(1):20-25. Previous Next

Stereotype of a Surgeon Heartless with a God Complex < Back Stereotype of a Surgeon Abrasive, intimidating, self-confident, egotistic, stubborn, arrogant, difficult to work with, aggressive, competitive, and domineering, technically masterful, astute, energetic, and precise.(1) These are just a few of the adjectives that have been used to describe surgeons. The top Google autocompletes for the phrase "why are surgeons…” include arrogant, rough, rude, important, jerks, mean, cold, weird. There is a balancing act between the need to demonstrate confidence while maintaining our humanity and our humility. We wield sharp instruments, and we ask our patients to trust us to fix them while they lay naked and exposed, anesthetized, and vulnerable. So how do we reconcile these seemingly opposing characteristics? How do we show strength, leadership, and confidence in our decision-making and skills and also develop a rapport with patients and families? How do we show our patients that we will be with them to celebrate their recovery and stand by them in the face of complications and setbacks in their recovery? Effective communication is key to relationship building. In general, surgeons are not known for their stereotype that surgeons don't have the best bedside manner. "As a group, surgeons are not well known for their bedside manner."(2) We (usually) operate on completely unresponsive patients, so the stereotype that we don’t like talking to patients is not illogical. This stereotype extends to anesthesiologists. While this is a satirical representation, there is a kernel of truth in the idea that most don’t go into specialties that frequent the OR to spend MORE time talking to patients. "While poor manners aren't commonly accepted in most professional circles, representations of surgeons in popular culture often link technical prowess with rude behavior, and some surgeons have even argued that insensitivity can be helpful in such an emotionally strenuous profession."(2) I probably spend more time talking to patients and their families than the typical surgeon. I find these personal interactions to be truly remarkable. During my training, I developed my style for communication. When I share information with a patient and their family, I treat them as if it were my family member. Based on my perception of their interest in detail and my direct explanation that I will share as much or as little as they like, I tailor my interaction with each new encounter. I believe in full disclosure, including admitting when I don’t have the answers. My training has given me the confidence to admit when I need more information or plan to consult with a colleague. Some might see my willingness to admit imperfections as a sign of weakness. While I didn’t develop my practice regarding disclosure with the express intention of avoiding legal consequences, poor communication and lack of empathy are commonly cited in malpractice suits.(3) So besides the intrinsic benefit of developing respectful interactions with patients, the extrinsic factor of avoiding the courtroom is powerful. A study published in 2019 found that surgeons are regarded as high in warmth and competence, relative to other non-medical occupational groups,(4) in contrast with the stereotype that we lack social skills. The study also noted that female surgeons received higher warmth ratings than male surgeons, while male surgeons received higher competence ratings than female surgeons. It is not an easy task, but building trust with our patients requires us to instill confidence while maintaining our humanity. 1. Logghe HJ. History of Medicine: The Evolving Surgeon Image. AMA J Ethics. 2018;20(5):492-500. 2. Neilson S. When Surgeons Are Abrasive To Co-Workers, Patients' Health May Suffer. 2019 Jun. NPR. 3. Huntington B. Communication gaffes: a root cause of malpractice claims. BUMC Proceeding. 2003;16:157–161. 4. Ashton-James CE. Stereotypes about surgeon warmth and competence: The role of surgeon gender. PLoS ONE 14(2): e0211890. Previous Next

< Back Pancreatitis UpToDate Patient Education Patient education: Acute pancreatitis (Beyond the Basics) Patient education: ERCP (endoscopic retrograde cholangiopancreatography) (Beyond the Basics) Source: UpToDate Images: Pancreas Anatomy Previous Next

< Back Vent Mgmt #3: Pressures Inspiratory Pressures Pressure Controlled Ventilation (PCV) End-inspiratory pressure= alveolar pressure. The pressure is essentially constant during PCV- high flow at the beginning to get to target pressure, then flow tapers until it ends (no airflow at end inspiration). Can't measure resistance because flow rate is dynamic. Volume Controlled Ventilation (VCV) Peak inspiratory pressure (PIP)- maximal pressure with inspiration. Sum of plateau pressure and pressure required to overcome airway resistance. Keep <40 cm H2O, SCCM recommends below 30 for ARDS. Abnormalities: elevated PIP indicates high resistance (secretions, bronchospasm, biting tube). Plateau pressure= alveolar pressure. Mean pressure during end-inspiratory pause, basically when there is no air movement. Not affected by resistance. Goal ≤30 cm H2O. Abnormalities: elevated plateau pressure indicates poor compliance. Driving pressure= plateau - PEEP. Goal ≤15 cm H2O (>15 is associated with ↑mortality). PEEP can either improve or worsen driving pressure. If the set PEEP promotes recruitment→ ↓driving pressure. If the set PEEP creates overdistension of the alveoli→ ↑driving pressure. End Expiratory Pressure Positive end expiratory pressure (PEEP)- lowest pressure that avoids alveolar collapse, which occurs when intrapleural pressure is higher than intra-alveolar pressure. This is indicated by the lower bend on the pressure/ volume curve, known as the lower inflection point. Mean Airway Pressure Mean airway pressure (MAP)- average pressure the lungs are exposed to during the breathing cycle. One of the two parameters that determine oxygenation. - How to increase MAP: ↑PEEP. If using IRV, ↑inspiratory time (Thigh) and ↑inspiratory pressure (Phigh). Parameters that Impact Airway Pressures Resistance- change in pressure relative to flow (PIP - plateau/ peak inspiratory flow). Relationship between PIP and plateau is directly related to airway resistance. ↑PIP and [PIP - plateau >5 cmH2O]= ↑resistance (bronchospasm, ETT obstruction/ kink). ↑PIP and ↑plateau [PIP - plateau <5 cmH2O]= ↓compliance (PTX, ARDS, pneumonia, edema, auto-PEEP). Compliance- change in volume per change in pressure. Normal- 50-100 mL/ cm H2O Previous Next

< 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

< Back Pack the Guts Previous Next

Your Words Matter...And OCD isn't an Adjective "That's So Gay" Your Words Matter...And OCD isn't an Adjective "A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder." - DSM V (Diagnostic and Statistical Manual of Mental Disorders) Psychiatric disorders are a constellation of traits that impact a person's interaction with their environment. A formal diagnosis is based on a constellation of symptoms as well as an assessment of how functional the person is in their daily life. These disorders are outside the control of the individual, and they are pervasive in a way that interferes with daily life. We all have traits that could fit with a psychiatric diagnosis, but that doesn’t permit us to use the diagnosis as an adjective. We've all heard someone call themselves ADD because they're occasionally distracted or forgetful. People might call themselves or someone else OCD if they like a neat tidy environment. Bipolar is frequently used to describe (or insult) emotional people. What's the problem with using ADD as an explanation for occasional absent-mindedness, or calling someone bipolar because they are moody? Equating the presence of a trait of a disorder with an actual diagnosis minimizes the real struggle that many people experience every day. This is similar to using the words “retard/ retarded ” or “gay” to mean something is stupid or weird. In 2009, the Spread the Word: Inclusion campaign was created to eliminate the use of the “R-word”. In 2010, Rosa’s Law relabeled “mental retardation” to “intellectual disability”. The words “imbecile”, “idiot” and “moron” have also been relabeled as profound, severe, or moderate intellectual disability. The Stonewall Education Guides: Tackling Homophobic Language , which was published nearly 10 years ago (no date identified, but the document quoted literature published in 2012 describing “the previous 5 years”). They listed “that’s so gay” and “you’re so gay” as the two most commonly used homophobic phrases. They report that these phrases “are most often used to mean that something is bad or rubbish, with no conscious link to sexual orientation at all…a pupil might say ‘those trainers are so gay’ (to mean rubbish or uncool) or ‘stop being so gay’ (to mean stop being so annoying). Check out these PSAs discouraging people from using the phrase “that’s so gay”. "That's So Gay" Commercials Win Top Ad Council Award (starts at 1:16) Wanda Sykes Talks to Boys in a Diner Just like gay and retarded have been used out of their appropriate context to mean something is bad or stupid, here are some of the common traits that people mislabel as a "disorder" - OCD: excessive cleanliness, being overly tidy, “Type A” personality - ADHD: a tendency to make careless mistakes, forgetfulness, short attention span, easily distractable, tendency to interrupt conversations. - Depression: sadness, pessimistic, being an introvert - PTSD: bad memories associated with something trivial (the sound of a pager going off), bad dreams, fear of a particular event - Insomnia: occasional trouble initiating or maintaining sleep - Bipolar: moodiness, decreased need for sleep. - Anxiety: normal levels of anxious feelings It might not seem like a big deal- but try to imagine if you had a disorder that made normal interaction with your environment a struggle? Now imagine someone who can function normally but has a couple of “quirks” were to equate their experience with yours? You might feel that they are minimizing your disorder, invalidating your struggles- this might leave you feeling misunderstood and alone. Please think before you speak. Your words matter. 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

14 Scienceblind Why Our Intuitive Theories About the World Are So Often Wrong Intuitive theories- our best guess as to why we observe the events we do and how we can intervene in those events to change them. Infer causality from our observations. Similar to historical theories- how we used to understand things before we had the ability to understand the reality (like heat as an “object” versus “energy”). Emergent process- system wide (no clear cause/ effect explanation), equilibrium-seeking, simultaneous, ongoing. Heat, weather, evolution are all emergent processes. Molecular theory, scientific theory. Holistic theory- matter is continuous and has heft and bulk Intuitive theories of the physical world Matter- substances are holistic and discrete, instead of particulate and divisible. Conservation- clay flattened, water poured from short fat glass to tall skinny glass. The difference between weight and heft, volume and bulk? Energy- heat, light and sound viewed as substance instead of emergent property. Why can you touch the 400 degree air in the oven but not the pan itself (without oven mitts)? The pan transfers heat better than air. How do we change from viewing “sound” as an “object” to viewing it as “energy”? First, we stop attributing permanence (noise doesn’t continue forever), then weight (clock doesn’t become lighter with each chime) and then mass (noise can pass through a wall, doesn’t have to maneuver around wall). Extra-missionist- rays go out of the eye and then return to create vision vs intro-missionist- rays enter the eye to create vision. Gravity- weight is an intrinsic property of objects instead of relation between mass and gravity. Objects don’t fall because they’re heavy- they fall when they don’t have upward force on them that exceeds gravity (center of gravity). Motion- force is something transferred between objections (“impetus”), instead of external factor changing the objects motion. What path will an object take- for example, a ball in a spiral slide- takes straight path after exiting, doesn’t gain an inherent “spiral” motion. Cosmos- earth is a motionless plane orbited by the sun. Changing of the tides, seasons (tilt of the earth as it revolves around the sun, the side closest to the sun is summer). Earth- continents and mountains are eternal and unchanging vs transient/ dynamic. Tectonic plates- similar land features on different coasts. Greenhouse effect and global warming- humans causing it, but the earth will live beyond us. Vitalism- living things possess an internal energy, or life force, that allows those things to move and to grow. Essentialism is the idea that an organism’s outward appearance and behavior are products of its inner nature, or “essence.” Intuitive theories of the biological world Life- animals viewed as psychological agents vs organic machines. Death= cessation of biological processes. Growth- eating is for satiation rather than nourishment, aging is a series of discrete changes vs continuous change. Vitalism- living things possess an internal energy, or life force, that allows those things to move and to grow. Essentialism is the idea that an organism’s outward appearance and behavior are products of its inner nature, or “essence.” Inheritance- parent-offspring resemblance viewed as nurture, vs transfer of genetic information. Illness- disease is due to supernatural causes, instead of microorganisms. Adaptation- evolution is the transformation of an entire population (butterflies become slightly darker with each generation) vs selective survival (darker butterflies survive to reproduce). Ancestry- species develop linearly (monkey→ ape→ human) rather than branching from common ancestor. 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)

< Back Mentorship What is mentorship? Mentorship is a partnership between a more experienced and knowledgeable individual (mentor) and a less experienced individual (mentee) seeking to learn, develop skills, and advance their career in the healthcare profession. The mentor is typically someone who has achieved a level of success that the mentee aspires to reach. Through this relationship, the mentee, who could be a medical student, trainee (resident or fellow), or junior staff member, can benefit from the mentor's expertise and past experiences, gaining valuable insights into the healthcare profession. The mentor can serve as an advisor, consultant, or coach depending on the mentor's expertise and the mentee's needs. For example, a mentorship relationship can be designed to help the mentee improve clinical skills, navigate the job search process, or advance research endeavors. It's common to have different mentors for different purposes, as each mentor may have different strengths. Mentorship also provides networking opportunities, as the mentor can facilitate connections between the mentee and other professionals in the field. In summary, mentorship is a valuable tool for professional development in healthcare, offering guidance, support, and connections that can help mentees achieve their goals. Do I really need a mentor? Throughout medical school and residency, I didn't have any formal mentors, but I did actively seek the opinions, advice, and feedback of several surgeons I respected. As a young staff surgeon, I still didn't actively pursue mentorship, though I now recognize that it could have been highly beneficial. My first formal mentorship relationship was late in my training, when I was an Acute Care Surgery fellow and I was required to choose a staff member as a mentor. It's not uncommon for trainees to lack mentors, and one possible explanation resonates with me. "Many young people today who end up in residency…have been on a fast track. They’re essentially high-achieving, highly driven professional students who have been on a fairly regimented pathway…and they haven’t reached a point where there are multiple pathways they could take."(1) As someone who has been on a straight path since high school, progressing from high school to medical school to residency to being a junior faculty, I potentially missed out on a valuable asset. It's important to note that having a mentor is not a requirement, but developing a strong relationship with a mentor can positively influence one's success. It's highly recommended that individuals consider formal mentorship, but it's equally important to recognize that they have the ability to end relationships that are toxic or not a good fit. How do I find a mentor? Mentorship relationships can be an essential aspect of professional growth for medical trainees. These relationships can develop organically or be assigned by program directors in residency or fellowship programs. If you are assigned a mentor, it can be a great experience, but it is also possible that you may not mesh well if the assignment was not carefully considered. It's essential to recognize that if you find yourself in a mentor-mentee relationship that is not productive, amicable, or beneficial, it's okay to end the relationship and seek out another mentor. On the other hand, organic mentorship relationships can also be incredibly fruitful. As you work with various individuals in different settings, such as the operating room, during rounds, or while discussing consults, you will begin to form opinions and may find that you gravitate towards a particular person. If you respect and trust them and they demonstrate skills or expertise that you want to learn from, they might be a viable option as a mentor. The process of finding a mentor can be as simple as asking the person you would like to work with if they would be willing to mentor you. Remember, the worst they can do is say no, so it's worth taking the risk to ask. If they don't have the time to commit to being a mentor, they may be able to connect you with someone else who could be a good fit. It's important to recognize that mentorship relationships require effort from both the mentor and the mentee. While your mentor can offer guidance, support, and feedback, it's ultimately up to you to take ownership of your own professional development. Be clear about your goals, seek out feedback, and be receptive to constructive criticism. By putting in the work, you can make the most of your mentorship relationship and set yourself up for success in your career. Finding a mentor can be a great way to help you achieve your personal and professional goals, but it's important to have a plan in place to make the most of the relationship. Here are some steps you can take after finding a mentor to ensure that you get the most out of the relationship: 1. Set specific goals: Take some time to think about what you hope to gain from your mentorship. Are you looking to improve your skills in a particular area? Do you want help navigating a career transition? By setting specific goals, you can make sure that you and your mentor are on the same page and working towards the same objectives. 2. Establish communication: Once you've set your goals, it's important to establish how you will communicate with your mentor and how frequently you will meet. This can be done through formal meetings, phone calls, or casual chats over coffee. Make sure that both you and your mentor are comfortable with the frequency and type of communication. 3. Complete assignments or tasks: Your mentor may assign you tasks or provide you with guidance on specific projects. It's important to take these assignments seriously and complete them as directed. This could be anything from revising your CV to drafting a study protocol. By following through on these tasks, you can demonstrate your commitment to the mentorship and make progress towards your goals. 4. Reassess and refine: As you work with your mentor, it's important to regularly reassess your progress and refine your goals. This may involve checking off completed tasks, adding new objectives, or removing items that are no longer a priority. By keeping your goals current and relevant, you can make sure that you are making the most of the mentorship. Overall, finding a mentor can be an incredibly valuable experience. By taking the time to set goals, establish communication, complete assignments, and reassess your progress, you can make sure that you get the most out of the relationship and achieve your personal and professional objectives. 1. Darves B. Physician Mentorship: Why It’s Important, and How to Find and Sustain Relationships. NEJM Career Center. 2018 Feb. 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