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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 Wound Care American College of Surgeons: Home Skills for Patients Adult Colostomy/Ileostomy - collection of resources to help you prepare for managing your ostomy, including videos and a home skills kit. Your Colostomy/Ileostomy Ostomy Home Skills Kit: Adult Colostomy/Ileostomy Wound Management Home Skills Program Drain Care Jackson-Pratt (JP) Drainage Tube: After Hospital Care [Northwestern Medicine] Previous Next

< Back Guts on the Floor and Exposed Spine Patient #1 A 32-year-old male was involved in a head-on motor vehicle collision. He was ejected and pinned between two vehicles. He was brought in by EMS and on arrival to the trauma bay, he was covered with a sheet. When he was transferred to the gurney, it was clear that there was something unusual. He was eviscerated with a large wound in his right lower abdomen just above his inguinal ligament, and his intestines were entangled in his clothing. Patient #2 A patient was brought in by EMS following a motorcycle accident with a report of "exposed spine". Primary survey unremarkable, hemodynamically stable. FAST revealed fluid in the abdomen. A secondary survey revealed multiple extremity abrasions. When the patient was log rolled, he was noted to have a full-thickness degloving injury of the soft tissue and partial avulsion of the back musculature with exposed spinous processes. What are the management priorities? Prioritize primary and secondary survey, treat life-threatening injuries first. Secure airway. Evaluate for concomitant injuries, including thoracoabdominal injuries, requiring emergent surgical intervention. The challenge of Distracting injuries Remember- very painful or frightening injuries may distract from pressing clinical priorities. Regardless of how horrifying or novel an injury is, the goal of rapid evaluation and management of trauma patients is to identify and treat the most life-threatening injuries first. Remember to evaluate the airway, breathing, and circulation, and don't be concerned with the exposed intestine until you have ensured the patient doesn't have a pending loss of airway, tension pneumothorax, cardiac tamponade, etc. Control active arterial hemorrhage. Don't let the patient die from an unsecured airway while you are frantically attending to grass and flecks of wood and rock covering the exposed back muscle overlying the spine. Previous Next

< Back Snowboarding Gear and Resources I currently ride a true twin snowboard. Brand- Arbor Cadence Size- 147 cm Profile- System Rocker What kind of board I'm looking for? All-mountain Shape- directional twin Profile- rocker/ reverse camber Flexibility- medium Website Links On the Snow Up-to-date information about snow conditions. Projected resort opening/ closing dates. State Level Information- V irginia Snow Report Specific Resort Information- Jay Peak Apps On the Snow (see above) Epic Pass Slopes How to Choose a Snowboard Snowboardingdays.com REI.com How to Set Up Your Snowboard Burton.com Mounting Burton Bindings Miscellaneous Seven Most Dog-Friendly Ski Resorts in North America Previous Next

< Back ICU Society of Critical Care Medicine (SCCM): Patient and Family Resources Meet the Critical Care Team Learn about the members of the ICU care team. Patient Communicator Application This free app by SCCM is designed to improve communication between patients, families, and caregivers. Critical Care FAQs Learn about which patients require care in the ICU, what things commonly happen in the ICU, as well as find a more detailed explanation of common medical conditions seen in the ICU. Resource Library The MyICUCare.org Resource Library includes complimentary materials aimed at educating patients and families about the critical care journal, both during an ICU stay and after discharge. Understanding Your ICU Stay: Information and Patients and Families booklet. American Thoracic Society- Patient Education | INFORMATION SERIES Managing the Intensive Care Unit (ICU) Experience: A Proactive Guide for Patients and Families Mechanical Ventilation What is Acute Respiratory Distress Syndrome? What is ECMO? Central Venous Catheter Arterial Catheterization What is Hemodialysis for Acute Kidney Failure? What is Sepsis? Palliative Care for People with Respiratory Disease or Critical Illness Tracheostomy in Adults Living with a Tracheostomy Venous Thromboembolism- Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) Preventing Venous Thromboembolism [John Hopkins Medicine: Armstrong Institute for Patient Safety and Quality ] Previous Next

11 Made to Stick Why Some Ideas Survive and Others Die 6 Principles of Sticky Ideas - Simple - Unexpected- crash at the end of the car commercial. - Concrete - Credibility- the ability to test. Before you vote ask yourself if you are better off today than you were 4 years ago- Reagan. - Emotions - Stories Curse of knowledge- we find it hard to imagine not knowing what we have learned. Can’t imagine what it’s like not to understand a certain concept that we accept as fact Previous Next

< Back The Trauma Bag Why was there a need for a trauma bag in the hospital? As an acute care surgeon responding to trauma activations, airway emergencies, and a variety of other hospital surgical emergencies, there are a handful of supplies that I always have with me. The two basics are a scalpel for surgical airways and trauma shears (classically used to remove clothes in the trauma bay, but I seem to find more uses all the time). Eventually, I added a Kelly clamp to my armamentarium- handy for disconnecting or unscrewing a wide variety of impossibly tight connections or securing something in place. During the COVID Pandemic, numerous changes were made in our hospital to minimize infection transmission. Unfortunately, several of the modifications had unintended negative consequences. When we stopped wearing white coats, we lost our pocket space for stashing scalpels and shears. We also carried more gear, including eye protection and N-95 masks (carried in a brown bag when not worn). Many surgeons adapted by using an assortment of bags, such as sling backpacks or CamelBak cases. My own choice is this fanny pack , which draws many compliments! The next challenge was the relocation of supplies from the wall of our trauma bay onto shelves in the hallway. Team members had to leave the trauma bay, locate which cart the item was on, and then scan for the item, which created delays. This disrupted communication as well because team members missed changes when they were outside the room. Another hurdle that existed even before the pandemic was the array of different names for the same item. Most people who place cotton-tipped applicators in their ears after their shower call them by the brand name “Q-tip”…they are actually called “cotton tip applicators” or “CTA”. **Note- don’t use Q-tips in your ears!** Drop the Q-tip! Why ENTs are begging you to leave your ears alone. The surgeon might ask for 4x4s, which is what we call gauze in the operating room. Some say "Quik-Clot” while others know the product by the name “Combat Gauze”. Sutures are a whole other bag of worms…do you use silk or Ethibond to secure your chest tube? Curved or straight needle? Countless times, the trauma chief is managing the trauma and when someone calls for a suture, their attention is often diverted to advising the person reaching into the suture box on the wall.…"no, the one to the left, top row." It’s not always easy to tell from the box what the suture and needle look like. In addition to the elimination of white coats, relocation of commonly used supplies outside the trauma bay, and different names for supplies, I noticed that several key items were frequently used and they seemed to be unreasonably challenging to locate in a timely fashion. Combat Gauze, Coban, specific suture on a specific needle, etc. Therefore, I created a backpack of supplies that I carry when on call. What does this bag do? This bag was created from my perception of a necessity to ensure specific supplies are readily available when responding to surgical emergencies. A Level 1 trauma center is equipped with the highest level of resources and personnel to manage the most complex patients, and our resources and patient population dictate what supplies are needed on a routine basis. My focus was on supplies that are (1) frequently used, (2) unique and not readily available in all locations where they are used, and when they are required, (3) delays in employment are remarkably morbid, and (4) portable. Why didn’t I include tourniquets? They’re frequently used and delays in employment are morbid, but patients typically have them in place on arrival and if not, they are readily available in the trauma bay. Why didn’t I include chest tubes? They are frequently used and delays in employment are morbid, but they are relatively widely available. In addition, the life-threatening physiology of hemothorax or pneumothorax can be resolved with a finger thoracostomy using a scalpel and Kelly (essentially the same process as placing a chest tube, but stopping at the step of a finger sweep in the thoracic cavity, releasing massive hemothorax or tension pneumothorax). Why didn’t I include a REBOA kit? This is a controversial topic. However, in the situation where resuscitative thoracotomy is deferred in favor of REBOA, rapid employment is ideal. However, this device is not frequently used at our facility. Paper clips? In a trauma bag? Yes, paper clips. They are used to mark wounds for creating a road map of the trajectory. What DOESN’T this bag do? This is NOT an all-inclusive bag for responding to all emergencies. It should not be considered a guide for pre-hospital emergency response, non-surgical emergencies, or any situations outside of the specifications reviewed above. There are other response teams in the hospital that have different supplies. For example, we have ICU nurses that respond to rapid response or code blue situations, and they carry critical care transfer bags. I don’t know the list of supplies that they carry, but here is a sample of potential contents of a “transfer bag”. In summary, my trauma bag is focused on specific needs that I perceived based on my daily work at my facility. If you perceive a need for a similar tool at your facility, I would encourage you to develop a supply list tailored to your needs. Trauma Bag- Supply List Personal Protective Equipment Blue gown, non-sterile (2) Medium gloves Mask with eye shield (1) Sterile Supplies for Procedures Pack of blue towels (1) Stapler (1) Sterile gown (1) Small Chloraprep (2) Laceration tray (1) Dressings and Hemostatic Agents Gauze, 4x4 (2) Surgicel, 2 in x 3 in (4) Quik-Clot, 3 in x 4 yds (3) Kerlix, 3.4 in x 3.6 yds (3) Kerlix, 4.5 in x 4.1 yds (1) Coban, 4 in x 5 yds (1) Large Tegaderm (4) Sutures and Instruments #1 Ethibond, curved needle (8) #0 Silk, straight needle (4) #0 Silk, curved needle (1) #2-0 Silk, curved needle (2) #2-0 Vicryl, curved needle (5) Skin stapler (1) Adsons (1) Kelly clamp (2) Needle driver (1) Laceration tray (1) Scalpel #10 (1) Scalpel #11 (1) Miscellaneous Cotton tip applicators (3) Tongue Depressors (2) Paper clips Disclaimer: This was created early in the pandemic, while I was a fellow at a different institution. Previous Next

1st day in radiology: your right is your left, your left is your right Radiologic Dyslexia < Back 1st day in radiology: your right is your left, your left is your right I have recently coined a new phrase. While showing my mom a picture, pointing out someone she had never met before, I commented, "he's the one on the right." Funny story, though- he was actually on the left side of the picture. I had to pause while I talked to my mom and reassure her that I know the difference between my right and my left. While scrolling through Twitter the other day, I was reviewing a question posed about an abdominal x-ray. Another Twitter user added a helpful hint by indicating "the right side of the circle" when pointing out an abnormality. I predicted he meant anatomical right (meaning the image's left side) based on my interpretation. We chuckled about the discrepancy between radiographic laterality and left-right differentiation in real life. I decided to designate this mix-up "radiologic dyslexia." Feel free to use this in the appropriate context! Previous Next

< Back Vent Mgmt #4: All Together Choosing a mode Controlled- patients who aren't generating breaths. PC, VC. Most common mode at initiation of MV. SIMV- patient generating some breaths, but still needs significant mechanical support. Spontaneous- not frequently used at initiation, but can be used for patients with airway obstruction and preserved lung function. How to set initial parameters TV (6-8 mL/ kg predicted body weight) [lung protective ventilation] RR 10-14 FiO2 often start at 100%, but quickly weaned unless severely hypoxic Inspiratory:expiratory ratio typically 1:2 Flow- typically set @ 60L/min, can increase if the patient is in distress or has a high minute ventilation How to adjust parameters based on arterial blood gas results Low PaO2 (low arterial oxygen content)- increase FiO2, increase mean airway pressure Markedly elevated PaO2 (hyperoxia)- decrease FiO2 Low PaCO2 (low arterial carbon dioxide concentration)- decrease TV or RR High PaCO2 (high arterial carbon dioxide concentration)- increase TV or RR *For more details, check out these resources: Lectures: Critical Care: Respiratory Failure Lectures: Critical Care: Vents Other principles of mechanical ventilation VAP bundle- elevated head of bed, oral care Daily awakening and spontaneous breathing trials Previous Next

< Back Free Fluid in the Abdomen A 62-year-old male presents following a motor vehicle collision in which he was an unrestrained driver. He was intubated in the trauma bay for decreased mental status. A focused assessment with sonography for trauma (FAST) was performed, which did not reveal intra-abdominal fluid. Computed tomography (CT) of the head demonstrated minimal intra-cranial injury. CT of the abdomen and pelvis (see below) revealed decreased blood supply to the left kidney, small irregularity of the splenic contour, and a moderate amount of free fluid in the abdomen and pelvis. Hounsfield units are consistent with simple fluid. CT of the abdomen and pelvis https://video.wixstatic.com/video/3b6ff6_b03419943e9941d281c3d8f0b800e37f/480p/mp4/file.mp4 What is the differential diagnosis for the free fluid in the abdomen? Free fluid due to trauma can be urine, enteric contents (bowel injury with spillage of succus) or blood. It is possible to have fluid present prior to the trauma, such as ascites from chronic liver disease. In this case, the free fluid in the abdomen had characteristics of “simple fluid,” based on Hounsfield units, suggesting that the fluid was not blood. In females, free fluid in the pelvis can be normal (physiologic fluid). However, free fluid is NOT normal in a male, and it's concerning for hollow viscus injury. What are the possible causes of decreased blood flow to the kidney? The renal artery can be injured in blunt trauma. Blunt injury can disrupt the layers of the artery wall, leading to thrombosis and decreased blood flow beyond the injury. He was admitted to the intensive care unit. A foley catheter was placed and demonstrated pink-tinged urine [NOT frank gross blood/ clots]. What are the possible causes of blood-tinged urine? Bloody urine indicates a traumatic injury to the genitourinary tract, anywhere from the kidneys down to the urethra. A CT cystogram was performed, which did not reveal any extravasation of contrast from the bladder. CT Cystogram https://video.wixstatic.com/video/3b6ff6_119074429b224cc98677d4f101fef666/480p/mp4/file.mp4 Next steps? Based on an unreliable physical exam and a normal CT cystogram, it is necessary to rule out bowel injury. The patient was hemodynamically stable and had normal laboratory values. He remained with a decreased mental status, and therefore serial abdominal exams were not a viable management plan. The patient was taken to the operating room and underwent diagnostic laparoscopy. His small bowel, colon, and mesentery were examined in there entirety and found to be completely normal. There was a small amount of clear thin fluid in the pelvis, but there was no evidence of bile staining or bleeding. After completing the evaluation of the gastrointestinal tract, we repositioned the patient in Trendelenburg. The pelvis was inspected, and it was quickly apparent that the patient in fact had a large defect in the dome of the bladder. We elected to proceed with a low midline laparotomy. The bladder was easily mobilized, and the extent of the defect was defined. The edges were grasped, and the defect was closed in two layers with absorbable suture. Postoperatively, we reviewed the preoperative CT cystogram. In retrospect, there was a suggestion of bladder irregularity. We reviewed the CT cystogram with the radiologist and there was no evidence of contrast extravasation. However, the bladder does not appear to have been completely distended with contrast. It is very atypical that a large bladder wall defect was not associated with contrast extravasation, and this highlights the importance and ensuring complete filling of the bladder with contrast. Evaluation and Management of Bladder Injuries Bladder injuries can occur from blunt or penetrating trauma. For example, bladder injuries can occur when blunt force is exerted on a full bladder or in the setting of a pelvis fracture. Diagnosis Gross hematuria is seen in most patients with bladder injuries. Cystography, either using plain x-ray or CT, is the diagnostic test of choice. Management The management of bladder injuries is based on location. Intra-peritoneal injuries require operative management. This is done in two or three layers with absorbable suture. A decompressive foley catheter is left following repair. Extra-peritoneal injuries can typically be managed non-operatively with a foley catheter for 10-14 days. Exceptions include large bony segments protruding into the bladder wall, associated rectal or vaginal injuries, bladder neck injuries, or an associated pelvic fracture undergoing operative intervention to prevent hardware contamination. Current guidelines recommend a cystogram before foley removal, except for the most uncomplicated injuries. Yeung LL et al. Management of blunt force bladder injuries: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2019;86(2):326-336. Previous Next

< Back Fever...pending Evaluation of Fever Previous Next

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