4 Everything is Obvious ...Once You Know the Answer - Countless examples of how we understand cause and effect much less than we think. - "No matter where we live, our lives are guided and shaped by unwritten rules-so many of them, in fact, that we couldn't write them all down if we tried." - The relative number of people who are organ donors varies between countries. Why? Religion, education, fear about receiving less aggressive care if you are an organ donor, et cetera. The default option for registration can explain the difference between two neighboring European countries. One country requires the citizen to actively elect to be a donor, while another country requires a citizen to decline the default option for being a donor. - "We claim...that the Mona Lisa is the most famous painting in the world because it has attributes X, Y and Z. But really what we’re saying is that the Mona Lisa is famous because it’s more like the Mona Lisa than anything else." 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

Maintaining our humanity in the clinical environment Comfortably Numb < Back Maintaining our humanity in the clinical environment If you are working in an intensive care unit, your patients will frequently be intubated and/ or sedated. The ICU can be very dehumanizing, and it is easy to forget that patients are human beings with family and friends that love them. Adherence to critical care guidelines and following protocols is important. But while we are providing the highest level of care based on evidence, we must not ignore the humanity of our patients. There is a missing link that isn’t routinely taught in school or nurtured in training and isn’t encouraged when it is performed. The human connection, treating a patient like a person. Treat your patients as if they were your family member. Basic human decency supports the practice of avoiding derogatory conversations in the presence of patients. I have witnessed more than a handful of incidents of medical personnel discussing other patient scenarios in the presence of other patients. HIPAA laws aside, generic simple conversations are likely unavoidable (“hey the patient next door needs his pain medication…”, “is room 7 ready for radiology…”, etc). However, I have witnessed providers speaking about a brain dead patient who was being evaluated for organ donation in the presence of another patient. Speaking about death and organ donation in the room of a critically ill patient is unacceptable. Mentioning derogatory things about patients in the operating room is unacceptable. My personal opinion is that negative things should be avoided in general. I don’t mean that real problems should be swept under the rug. But in my opinion, extraneous negative remarks have no place in a patient's room. A few thoughts. 1. Don’t lose your humanity. Treat all patients as if they were your loved one (family, friend, whatever fits that category for you). If you catch yourself slipping into a routine of just seeing the procedures and diagnoses, I urge you to engage in intentional self-reflection. 2. Treat all patients as if they can hear and sense everything. I am not a proponent of the occult or the metaphysical, and I don’t believe in jinxes- I don’t believe that mentioning bad prognoses makes them more likely to occur. However, I believe that most patients who are intubated and sedated are aware, on some level, of their surroundings. There are plenty of reports of patients recalling stressful experiences from their time in the ICU. I don’t think we will ever know what they can hear or sense, or how it impacts their emotional and physical well-being. Therefore, I strongly advocate for treating all patients as if they can hear and sense everything. 3. Try to imagine what you would want if you were in the patient's position. Imagine you can’t talk, you’re in pain, you have an itch you can’t scratch, your eyes are stuck shut from eye crust that you can’t wipe away, your mouth and throat feel like sandpaper, you don’t have your glasses or your hearing aids, you have no idea where you are or what day it is, etc etc. Now imagine you are slowly waking up as your sedation medicine wears off. You have people pinching you and yelling at you to open your eyes. Compare that to hearing a calm steady voice in your ear, speaking encouraging words, explaining that you are in an ICU, you have a breathing tube in place, you’re safe, your medical team is waking you up to see if you can breathe on your own and get the tube out. I’m not suggesting that this practice will eliminate agitation when a spontaneous awakening trial is performed. But just imagine the difference of being reoriented when you have no control instead of being shouted at and told to open your eyes. Imagine someone taking a wet washcloth to your eyes to remove the crust, allowing you to open your eyes for the first time in days. It’s not something you’ll learn in medical school. And it shouldn’t be revolutionary…but just imagine the difference in the patient's perspective and understanding of their situation. 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 < Back Board Examinations American Board of Surgery: General Surgery Boards Exam Prep Master the General Surgery Oral Boards by Dr Hassan Aziz . Dr Aziz reviews key surgical topics, including trauma, thoracic, pediatric, HPB, GI, breast cancer, endocrine, vascular. [Reference courtesy of Hassan Aziz, MD @Sharpknife_Aziz ] Surgical Education and Self-Assessment Program (SESAP). Resource for general surgeons- stay current with the latest surgical knowledge and prepare for examinations. American Board of Surgery: Surgical Critical Care Boards Exam Prep Evidence-Based Practice of Critical Care. 3rd edition, 2019. Reviews the literature regarding specific high yield critical care topics. Trauma, Critical Care, and Surgical Emergencies: A Case and Evidence-Based Textbook. 1st edition, 2010. 64 cases that review the basic principles of ACS. Previous Next

< Back Abdominal Pain- Renal Disease A 72-year-old male with multiple medical co-morbidities presents with several weeks of right-sided abdominal pain. His family reports he hasn't been eating or drinking much. He has a slightly altered mental status and was unable to provide any more detailed history of his symptoms, such as aggravating/ alleviating factors or the relationship of his pain to meals. His medical history is significant for poorly controlled diabetes with neuropathy and renal insufficiency. He has not seen a primary care provider in over 6 months. On exam, he is uncomfortable but not in acute distress. His heart rate is in the 100s, and his blood pressure is normal. He is febrile to 101. He has dry mucous membranes. He has tenderness in the right upper quadrant with a positive Murphys sign. His exam was otherwise unremarkable. Workup? Imaging- right upper quadrant ultrasound Laboratory evaluation- CBC, basic metabolic panel, AST/ALT, bilirubin His labs are remarkable for mild leukocytosis and an elevated Cr (baseline 1.2, currently 2). Imaging was remarkable for cholelithiasis and gallbladder thickening. The EGS team is consulted and the patient is admitted to the surgical ICU given his acute on chronic renal insufficiency. What are the possible etiologies of his renal insufficiency and the initial treatment strategies based on the underlying cause? Pre-renal causes, such as hypovolemia, lead to decreased renal perfusion. Treatment involves volume repletion. Intra-renal causes, such as medication and acute tubular necrosis from sepsis, requires treatment of the underlying cause concurrent with volume repletion, treatment of electrolyte derangements and avoiding further nephrotoxin exposure. Post-renal causes, such as kidney stones or foley catheter malfunction, require relief of the obstruction. Based on the patient's history of decreased oral intake, he is at risk for acute hypovolemia, which can worsen his baseline chronic renal insufficiency. He was treated with volume resuscitation and close monitoring of his urine output. When should he undergo cholecystectomy? If cholecystitis was the precipitating cause, he would likely continue to worsen if his surgery was postponed. If hypovolemia was the precipitating cause, it would benefit from volume resuscitation, which can be administered throughout the operative course. If his renal insufficiency was not an acute change, and it was a slow decline since his last clinic visit, it was unlikely to significantly improve in a short time. The ICU team, EGS team and anesthesiology discussed the risks versus benefits of proceeding with surgery. Regardless of the etiology, postponing his surgery would be unlikely to improve his operative risk profile. We proceeded with laparoscopic cholecystectomy, and he returned to the ICU postoperatively for ongoing resuscitation and monitoring. Management of Renal Failure The causes of renal failure can be categorized into pre-renal, intra-renal, or post-renal. Acute infection can precipitate renal insufficiency, which is associated with poorer outcomes. Pre-Renal Caused by hypovolemia (dehydration) from decreased intake, nausea/ vomiting, excessive diuresis, third-spacing from acute inflammatory processes (pancreatitis), blood loss, inadequate replacement of insensible losses. The common final etiology in pre-renal causes is decreased renal perfusion. Treatment- volume replacement. Intra-Renal Multiple different intra-renal causes, including vascular or micro-vascular etiologies, glomerular disease, and interstitial disease (acute tubular necrosis, medications, and various precipitates such as myoglobin and crystals). The most common acute causes are medication and ATN from ischemic/ sepsis. Treatment involves management of the underlying etiology and supportive care. Post-Renal Caused by any obstruction from the renal pelvis to the urethra, including kidney stones, malignancy (can obstruct anywhere from the ureter to the bladder), retroperitoneal fibrosis, prostate enlargement, blood clots in the bladder or foley catheter malfunction. Treatment involves relief of the obstruction. Acute Cholecystitis with Renal Dysfunction Diabetes and severe cholecystitis (Grade III- organ dysfunction) are risk factors for increased mortality in patients with acute cholecystitis.[1] As noted in the discussion above, it is crucial to weigh the risks and benefits of operative intervention. If there is a modifiable risk factor, such as an acute cardiac event that is amenable to intervention. Escartin A et al. Acute Cholecystitis in Very Elderly Patients: Disease Management, Outcomes, and Risk Factors for Complications. Surgery Research and Practice. 2019;2019:9709242. 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

9 Black Swan The Impact of the Highly Improbable - Silent evidence- you can’t determine causality just by studying the successes. You don’t know the traits of the failures- they could be the same as the successes. Failed writers aren't necessarily bad writers. - The absence of evidence (no evidence of disease) doesn’t mean evidence of absence. - Recognize the unknown unknowns. - Mediocristan (finite limits- weight, height, etc.). Extremistan (boundless- income, book sales, retweets). - The turkey, which is fed every day until thanksgiving, doesn't realize he's getting closer to death. - When a black swan occurs, people rationalize in hindsight and state that it was inevitable. - Series of events preceding a particular situation doesn’t imply causality. We give narratives to make sense of events. - Humans are the victims of an asymmetry in the perception of random events. We attribute our successes to our skills, and our failures to external circumstances outside our control, mainly, to randomness. There is something in us designed to protect our self-esteem. - The law of iterative expectations. If I expect to expect something at some date in the future, I already expect that something now. Stone Age historical thinker is called to write about the events of the era. If he predicts the wheel, then the wheel already exists as a concept. - Different conclusions can be drawn from the same data. Every day you’re alive...you could be closer to death or immortality. 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

Practical Tips on Having a Difficult Discussion How Do I Do It? < Back Practical Tips on Having a Difficult Discussion This blog is complementary to the previous blog about becoming more comfortable with uncomfortable conversations. After many difficult discussions with families during my critical care fellowship, I finally became comfortable with uncomfortable conversations. It's impossible to develop a script to use for every conversation, but here are some of the techniques I've adopted over the years. Sit down in a private room, have tissues if appropriate. Make sure your phone/ pager won't interrupt the conversation. Have someone else with you. It’s always good to bring the patient's nurse, and there is often spiritual support staff (ie chaplains) who can accompany you and provide support for the family. Introduce yourself, and ask who everyone in the room is, specifically how they're related to the patient. "Nice to meet you, I'm really sorry it's under these circumstances." If it's your first conversation with the family, it's important to establish a foundation to build on (or establish the absence of a foundation). You can ask "what do you know so far" or "what's your current understanding of the situation"? This also allows them to express their current questions/ concerns. Judge their level of comprehension and adjust as needed. This does NOT mean being patronizing or imposing stereotypes. Pay attention to facial expressions and listen to their questions/ responses. It's easy to fall back into speaking medical jargon- you need to deliberately focus on using easily understandable words. Words that we use every day are meaningless to most people who aren't in the medical field. Keep the conversation brief and take frequent pauses. They don't hear everything you say, and they'll hear even less if you talk non-stop. Allow them time to process what you’ve shared, and allow them to ask any questions they have. Acknowledge that it’s common to be overwhelmed by the discussion. You can validate them by offering "I know I just told you a lot of information" or "I know this can all be overwhelming". It’s also helpful to say, “I’m sure you will think of other questions, please write them down so we can discuss them later” Encourage them to discuss things amongst themselves and provide them a quiet private place to regroup after the meeting. It’s also helpful to say, “I’m sure you will think of other questions, please write them down so we can discuss them later.” This validates their feeling and reassures them that they don't have to worry about remembering every detail. Specific difficult topics - Death and dying. Acknowledge that what they are feeling is normal- regardless of what they feel, it's normal. Denial, angry, scared, guilty, confused, conflicted, exhausted, numb. - When they are wrestling with the decision about transitioning to comfort care (colloquially known as "withdrawal of care", or crassly, "pulling the plug") and they've verbalized that they know it's what their family member would want, acknowledge how difficult that decision can be but also reaffirm that they are doing the kindest thing by honoring their family members wishes. For other helpful tips, check out "Sunburn". "For patients who are alive, concentrate on the ‘big picture’ and avoid the inclination to catalog every injury during this initial encounter. The primary concern in these settings often consists of survival, brain damage, paralyzation and other major morbidities. Again, an overabundance of information can be overwhelming." Velez D et al. SUNBURN: a protocol for delivering bad news in trauma and acute care surgery. Trauma Surg Acute Care Open. 2022 Feb 9;7(1):e000851. Previous Next

4 Trauma References General Reference GCS .pdf Download PDF • 78KB Injury Severity Scores .pdf Download PDF • 195KB Snakebite Severity Score .pdf Download PDF • 102KB Staplers.Sutures.Mesh .pdf Download PDF • 530KB Hemostatic Agents .pdf Download PDF • 18KB TEG .pdf Download PDF • 12KB TBI Brain Injury Guidelines .pdf Download PDF • 213KB Brain Trauma Foundation .pdf Download PDF • 148KB DVT in TBI .pdf Download PDF • 137KB Spinal Cord ASIA Score .pdf Download PDF • 1.98MB

4 < Back Trauma Resources Society Guidelines American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) Best Practice Guidelines Imaging Management of Traumatic Brain Injury Management of Orthopaedic Trauma Management of Geriatric Trauma Massive Transfusion in Trauma Recognition of Child Abuse, Elder Abuse, and Intimate Partner Violence Palliative Care Western Trauma Association Algorithms. Evidence-based critical decision algorithms in trauma. Pediatric Trauma Society. Guidelines and educational resources. Brain Trauma Foundation Guidelines. Concussion, prehospital and surgical management of TBI, pediatric TBI, prognosis in TBI, combat-related head trauma. Joint Trauma System: Clinical Practice Guidelines. Evidence-based guidelines developed by subject matter experts from both the military and civilian communities. Tutorials ER-REBOA PLUS Catheter , Prytime Medical. Quick Reference Guide. ER-REBOA PLUS Convenience Kit. ER-REBOA PLUS Catheter, Instrutions for Use. ER-REBOA PLUS Catheter, Product Video. Videos and Lectures Joint Trauma System: Emergency War Surgery Course. Lecture series based on JTS CPGs and the Emergency War Surgery Book. Trauma in a Flash. Brief videos on trauma topics, hosted by the Arizona Trauma Association. American College of Surgeons Resources Resources for Optimal Care of the Injured Patient, 2014. Framework for developing a trauma system. Compares the different resources available at Level 1, 2, and 3 verified trauma centers. "An ideal trauma system includes all the components identified with optimal trauma care, such as prevention, access, prehospital care and transportation, acute hospital care, rehabilitation, and research activities. Guidelines for Field Triage of Injured Patients Recommendations of the National Expert Panel on Field Triage, 2011. Basic algorithm for triage of trauma patients based on mechanism of injury, physiologic criteria, and anatomic region of injury. Stop the Bleed. Trains non-healthcare providers in point of injury treatment for massive hemorrhage. AAST Resources Brief Topic Reviews. COVID-19, Aspiration, Blunt Cardiac Injury, Blunt Splenic Injury, Child Passenger Safety, Clostridium Difficle, ICU Illness, Wound Care Instructions, Field Triage, Epidemiology and Injury Prevention, Mechanical Ventilation, Pelvis Injuries, Rib Fractures, Sports Concussions, Thromboembolic Disease, Trauma Systems, TBI Rehabilitation. CME Opportunities. Meet the Masters, high yield journal articles, in addition to countless other resources. Some are free, and some are $25 for non-members. Virtual Grand Rounds. AAST hosts virtual grand rounds, a web-based educational series Acute Care Surgery Fellow Educational Resources. 67 Educational Modules for ACS Fellows. Created by the ACS Committee. ONLY accessible by ACS Fellows. Previous Next