It's a Small World < Back And You Really Should be Nice to People The medical community is incredibly small and interconnected. This can be very beneficial, but can also create challenges if interpersonal discord arises. Word travels fast and it's easy to burn bridges. In the medical field, there is a palpable tension between certain specialties. Not every hospital has the same procedure for managing trauma. However, in the countless hospitals I've worked in, clinicians in Emergency Medicine and Trauma Surgery work hand in hand to manage severely injured trauma patients. We have different training experiences and different management styles. When we (Trauma Surgery) come down to the trauma bay to evaluate a patient, we are a visitor. Yes, in a busy hospital, we might be incredibly frequent visitors. But still, we are guests in another department's home. Despite the best intentions, and perhaps even because of varying perspectives on what is "the best" intention, it is not a surprise that the trauma bay can serve as a breeding ground for animosity,(1) unless there are deliberate efforts to prevent conflict. Thankfully, creating a common language and developing standard practices is possible through mutually developed protocols, as well as principles in ATLS. This is crucial to effective patient care. I am grateful that I completed my Acute Care Surgery fellowship at a hospital system with a phenomenal relationship with our Emergency Department colleagues. I won't exaggerate and deny any conflicts, but there was a culture of mutual respect and a common goal of optimal patient care that I had never experienced before. Why Does It Matter? I started this post to share a story of why it's important to be nice to everyone you encounter. I mean, besides the fact that I believe that we should be kind and compassionate to everyone. At one facility that I worked, there was a less than friendly relationship between surgery and the emergency department. Again, I will confess that I likely had several of my own negative interactions. However, my general principle is based on what I described above. I consider my behavior and attitude to be at least a basic level of respect and decency to the providers that I interacted with. In contrast to unpleasant providers, I appeared to be above average. About 5 years ago, I was preparing for a deployment. I had the misfortune of being attacked by several dogs and required a series of rabies vaccines, which delayed my medical clearance. Thankfully, one of the ER providers from my hospital was at pre-deployment with me. He called a senior medical officer and obtained clearance so I could proceed without delay. It would have been easy for me to dismiss this provider during any of our countless interactions. If I had been consistently less pleasant, I suspect that he would have maintained a basic level of decency despite my poor behavior. But it's unlikely that he would have extended himself to advocate on my behalf. You never know what interaction could make the difference, so we should be nice to everyone. 1. Why Can't Emergency Medicine and Surgery Just Get Along? EmCrit Podcast. Previous Next

< Back Machete Attack- Neck Trauma A 42-year-old male was brought from an outside hospital after sustaining deep, extensive penetrating wounds to the neck and forearms. When he arrived at the hospital, we noted defensive wounds on his forearms and a deep laceration across the anterior neck. The report from EMS was that the patient was assaulted with a machete. What are the management priorities? Prioritize primary and secondary survey and treat life-threatening injuries first. Don't be distracted with impressive wounds. Secure the airway and control active hemorrhage. He was initially seen at a small community hospital, where an endotracheal tube was placed through the tracheal wound, and then he was transferred to our facility. He was rapidly transported to the operating room for evaluation. What structures need to be evaluated? Vascular structures (carotid arteries, vertebral arteries, jugular veins) and upper airway/ digestive structures (esophagus, pharynx). The head and neck team was consulted, and they evaluated him in the operating room. The wound's extent was explored thoroughly. Surprisingly, there were no injuries to the vascular structures, and the injury was isolated to the airway. The endotracheal tube was exchanged for a formal tracheostomy and a stent was placed in the upper airway to prevent luminal narrowing while the repair healed. The wound was closed in layers. Management of Penetrating Neck Trauma WTA Algorithm Anatomy Zone 1 Clavicles/ sternum to cricoid Zone 2 Cricoid to angle of mandible Zone 3 Angle of the mandible to the skull base Hard signs- airway compromise, massive subcutaneous emphysema/air bubbling through the wound, expanding or pulsatile hematoma/ active bleeding, shock, neurologic deficit, hematemesis. Soft signs- hemoptysis, blood in the oropharynx, dyspnea, dysphagia, dysphonia, subcutaneous air, chest tube air leak, non-expanding hematoma, bruit/ thrill. Hard signs or hemodynamic instability→ ensure airway and transport to OR. No immediate operative indications? Depends on symptoms and the zone of injury. Zone 1 and 3- CTA to rule out vascular and aerodigestive injuries; assess the trajectory of injury. Injury→ repair. Concerning trajectory→ triple endoscopy (laryngoscopy, bronchoscopy, and esophagoscopy). Zone 2- symptomatic→ OR. Asymptomatic- serial exams or imaging. Operative approach The most common incision for exploration of neck wounds is along the anterior border of the sternocleidomastoid (SCM) muscle. Exposure of Zone 1 and 3 are more challenging and endovascular adjuncts are useful. Zone 1 may require median sternotomy with extension along the SCM. Zone 3 requires mobilization of the mandible. Zone 2 can be approached with a transverse cervical collar incision with SCM extension. - Tracheal injuries are repaired with monofilament absorbable suture. - Esophageal injury- debride unhealthy edges, ensure full exposure of mucosal defect, repair defect (single or double layer), buttress with SCM, or strap muscle. Place drain. - Combined tracheoesophageal injury- repair, and ensure repairs are isolated with interposition of a well-vascularized muscle flap. Previous Next

Blood Shortage < Back Life and Death Decisions in a Resource-Constrained Environment When resources aren't in short supply, patient care isn’t limited by access to resources. As we quickly noticed at the beginning of the COVID-19 pandemic, nationwide supply shortages can develop quickly. In addition to the continuously growing staff and supply shortage the nation is currently enduring, we now have a critical shortage of blood products. The categories of patients who receive blood transfusions are diverse, and my colleagues and I use this resource daily. So I'm going to ask the uncomfortable question. Have you ever been in a resource-limited environment where you were unable to provide every patient with the same level of care? Have you ever been in a difficult position to allocate supplies and medical care based on triage? And most recently, have you been forced to re-evaluate your transfusion practice in light of this severe blood shortage? Several months ago I had a tragic case of a young male who suffered penetrating abdominal and pelvic trauma. He had multiple injuries to his IVC, his right iliac as well as hollow viscus injuries. I had another trauma attending, a trauma fellow, and a chief resident in the operating room. We were simultaneously working in multiple body cavities. Initially, I was holding manual proximal aortic control at the diaphragmatic hiatus. This was modified to transthoracic aortic cross-clamp, which also permitted open cardiac massage. Unfortunately, despite 4 educated pairs of hands, the patient remained hemodynamically tenuous. We cross-clamped the aorta and continued aggressive blood product resuscitation. I lost track of how many products he received, but it was likely one of the highest volumes I've ever given a patient. I'm a young staff surgeon, and this was the first case where I was faced with the ethical dilemma of withholding further transfusion in the setting of surgical futility. He had injuries that we were working to control, and in isolation, each injury was easily survivable. However, he sustained a constellation of symptoms too severe to tolerate. Whenever the thoracic aortic cross-clamp was released, he became profoundly unstable. Inability to tolerate the removal of cross-clamp is incompatible with life. No one wants to be seen as giving up, admitting failure, or abandoning a patient. As I gain more experience, I become increasingly comfortable with uncomfortable situations. In the back of my mind, as each minute passed, I became progressively more cognizant of the fact that the patient's mortality was inevitable. I didn't verbalize this until much later in the case. But at one point in the case, when I heard the number of units of blood transfused, my sense that the patient was unlikely to survive became overwhelming. I was grateful to have a colleague with me to openly discuss the conflict of continuing to administer blood products in a patient with essentially 100% mortality. We are charged with caring for patients with the same level of care, indiscriminately- not withholding interventions based on our judgments of a patient's worthiness. Blood products are an extremely precious and limited resource, and shouldn't be used without thoughtful consideration. Verbalizing that continuing resuscitative efforts while a patient is still alive is not without consequence. There are people in the room who don’t have the same experience, who don’t understand that even though we can continue to fix injuries, further use of blood products would not help the patient. By extension, there could be a patient who needed blood to save their love who could be deprived access to that resource. It takes experience to make these difficult calls. So how do you gain this wisdom and how do you handle these situations? - You only gain this wisdom through experience. It can’t be taught, it can only be learned by facing similar situations. - Remember you're not working in isolation. You don’t have to make the decision alone. Enlist the support of colleagues and senior partners. - Verbalize your thoughts- this makes others in the room aware of the current clinical situation. This also can empower team members to offer suggestions. In challenging clinical situations, I commonly say "does anyone else have any ideas". Some teammates do not feel comfortable speaking up in a room of physicians/ surgeons, so this can open the floor for a frank discussion. Previous Next

< Back Ultrasound: Trauma E-FAST Purpose: identify acute traumatic pathology including presence of pericardial fluid, pneumothorax, and intra-abdominal fluid. Probe Can use curvilinear probe, but usually switch to the phased array for the cardiac view, so it might be easiest to just use a phased array for the whole study. The linear probe can also be used when evaluating for pneumothorax through the anterior chest wall. Abdominal Cavity Assess for fluid in 3 different regions of the peritoneal cavity. Can use curvilinear probe, but usually switch to the phased array for the cardiac view, so it might be easiest to just use a phased array for the whole study. Right upper quadrant- 1) between liver and kidney [Morrison's pouch], 2) tip of the liver in the right paracolic gutter, 3) lower right hemithorax Left upper quadrant- 1) between the spleen and kidney, 2) subdiaphragmatic space, 3) tip of the spleen in the left paracolic gutter, 4) lower left hemithorax Pelvic- males- between bladder and rectum, females- behind the uterus, anterior to the rectum (pouch of Douglas). Image in transverse and sagittal planes. Cardiac The phased-array or curvilinear probe can be used. The probe is placed inferior and to the right of xiphoid, pointed to left shoulder, with the probe in a horizontal plane (not directed to the bed). Identify presence of hemopericardium (4th trans-abdominal window of the FAST). Assess gross function (contractility). Assess volume status- full or collapsed left ventricle. Thoracic cavity- The “E” in E-FAST The linear probe is used to identify oresence of a pneumothorax. It is placed in the mid clavicular line, oriented cephalad-caudad, 3rd-4th intercostal space. Pneumothorax is present when there is lack of apposition of the pleural lining to the chest wall which leads to loss of lung sliding. Also no comet tail artifact or lung pulse, presence of a lung point (where the pleural surfaces meet, the junction between sliding and absence of sliding). The curvilinear or phased array probe can be used to identify hemothorax by visualizing fluid above the diaphragm in the upper quadrants abdominal views. References Society for Academic Emergency Medicine: FAST Exam Ultrasound Tutorial: FAST (Focused Assessment with Sonography for Trauma) scan | Radiology Nation Previous Next

< Back Operating General Surgery Texts Chassin's Operative Strategy in General Surgery: An Expositive Atlas. 5th Edition, 2022. Zollinger's Atlas of Surgical Operations. 11th Edition, 2021. Operative Dictations in General and Vascular Surgery. 2012. Acute Care Surgery Texts Operative Techniques and Recent Advances in Acute Care and Emergency Surgery (Aseni). 1st edition, 2019. Surgical Decision Making in Acute Care Surgery. Atlas of Trauma/Emergency Surgical Techniques. Top Knife (Mattox). 1st edition, 2004. High yield of trauma operative management. Back to the basics. Atlas of Surgical Techniques in Trauma (Demetriades). 2nd edition, 2020. Anatomic Exposures in Vascular Surgery (Wind). 3rd edition, 2013. Key anatomic exposures for less commonly encountered injury patterns. Recommended by Dr. Feliciano at AAST 2020 Conference. Videos Surgical Stabilization of Rib Fractures and Cryoablation. Collection of videos of different surgical approaches. WebSurg. Free access to expert videos of minimally invasive surgery. Highly recommend. The Toronto Video Atlas of Surgery. Free access to expert videos of GI operative procedures. [Reference courtesy of EJS @ElliotJScottMD] Difficult Cholecystectomy: A learning module for laparoscopic cholecystectomy How to Tie Knots Like a Heart Surgeon How to Secure Chest Tubes (Soweto Tie) Previous Next

< Back Organizational Hacks How not to lose everything All my life, I've been forgetful and easily distractible. I joke that I'd lose my head if it wasn't attached. This challenge is part of my ADHD, and I can't overcome it with sheer willpower. The list of things that I've lost over the years is staggering- homework (oh so much homework…it was usually stuffed somewhere in my locker), clothing, books, charging cables, water bottles, earrings (what am I supposed to do with the remaining single earrings?) and a white polar bear stuffed animal (he was left in a hotel room on a road trip as a child). I'm looking forward to learning where all my things went when I die and go to heaven. So if this can’t be overcome with sheer willpower, how can you adapt? Check out these techniques or tools to see if you find something that would be useful for yourself. Information * Create a tool for yourself for storing the data you need to be able to access reliably. This website is full of high-yield medical information that is rapidly accessible, but a website is a labor-intensive option. You don’t have to invest time and money into a website. Here are some other options (check out this post for more details ): - Invest in a planner . Electronic options that sync are useful because they minimize the need to re-write things in multiple places. Another option that I prefer is one notebook that keeps all my events in one place, along with my collection of lists and reminders. - Write everything down. My planner is my note repository. The Apple Notes application is also useful because it can sync across multiple Apple devices. At home or work, dry-erase poster paper can be used to take notes, keep track of schedules and provide reminders for long-term tasks and due dates. - Trello is a user-friendly free application with multiple functions, including the creation of lists, storage of documents, and the ability to share notes or documents among team members/ family members. Items * Magnet strips . Using magnetic sheets the size of business cards, cut pieces and strips to put on various items and stick them to the fridge or other magnetic surface of your choice. For example, if you use dry-erase poster paper on the refrigerator, thin strips of magnet can be cut to fit along the length of several dry eraser markers, so they're always on hand when you have something to jot on the whiteboard * Keys on a hook by the front door. 3M hooks work well, but the hook design isn’t as important as placement, ideally not in direct sight of the door. You can also hang your work ID badge or any other small items you need when you leave the house. * Keep track of all your cords with these tie wraps . Inexpensive and sturdy. I didn’t think there was any way I’d use 50- I figured maybe a couple, just for a handful of my charging cables that always end up in a jumble. But trust me, you'll find plenty of uses for them! Finances and Important Documents * Save receipts for anything valuable. If it was purchased online, download the digital receipt. Use the "Create PDF" function to combine receipts. For paper receipts, an envelope in a drawer is a simple option. Every so often, review the receipts, and if there is anything you don't need anymore, toss it. * Paper shredder . Anything with personal information should be destroyed before being thrown away. This is technically not about avoiding losing something, but it’s an important task so it is included here. * Taxes. Instead of waiting until tax season, keep track of key documents and expenses throughout the year. A running spreadsheet of business expenses, donations, etc, can avoid the frantic search in March. * Metal rack of hanging file folders. Each folder has a different label, including taxes (donation receipts, investment statements, etc), moves (signed leases, welcome packet with key information, etc), and business (bank paperwork, original EIN and registration forms, deposited checks). Previous Next

< Back Pulmonary Embolism...pending Diagnosis and Treatment of Pulmonary Embolism Previous Next

End of Life Issues < Back Brain Death and Organ Donation Death can be uncomfortable and challenging to face/ navigate. Here are some of the situations that can arise surrounding the issue of death and organ donation. - Is resuscitating a patient with a devastating TBI for organ donation preservation justified? It may seem opportunistic and NOT focused on the dignified care of the patient- but it the patient’s desire would be to donate, preserving that option DOES honor their wishes. - If a patient is declared dead, specifically brain dead or death by neurologic criteria, and they previously expressed desire to be an organ donor (such as registration with an OPO or indicating their desires on their drivers license), legally the family can’t prevent the patient from donating. Even if the family opposes it, legally the patient should proceed to donation. But what about the risk of “bad press”? You’re honoring the patients wishes although that fact may be less apparent to the public compared to the anger expressed by the family members that the hospital “stole their loved one’s organs against their wish” or even worse, implying that the hospital “allowed” the patient to die so they could use their organs. - You don't need consent to perform a brain death test. Previous Next

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

Are you sure? < Back The Challenges of Being A Female (Acute Care) Surgeon My 17-year journey to become an Acute Care Surgeon started when I applied for medical school in my senior year of high school. I went to a 6-year combined-degree medical school and then completed a 6-year surgical residency. At age 29, I began my practice as a General Surgeon. After 3 years as a Staff Surgeon, during which I had one combat deployment and one medical readiness exercise in Africa, I then chose to complete an acute care surgery fellowship. Our acute care surgery department was comprised of 14 surgeons, only 3 of whom were female. Surgery has historically been a male-dominated specialty, and female surgeons continue to face significant obstacles.(1) There has been a noticeable shift with more females choosing surgical specialties, although they continue to be under-represented in trauma. This can create a sense of rivalry or competition, the need to be seen as equally competent as our male colleagues. On top of the difficulties inherent to surgical training and practice, the constant pressure to live up to expectations can foster stress and doubt. Imposter syndrome, which is "a psychological pattern in which people doubt their accomplishments and have a persistent, often internalized fear of being exposed as a ‘fraud’," can result.(2) Are You Sure This is What you Want to Do? Twelve years ago, during my internship, I was in the process of reapplying for the remaining 5 years of my surgical residency (a phenomenon that was subsequently eliminated from military surgery residencies). As I asked one of the senior (male) surgeons for a letter of recommendation, he discussed the issue with me in the middle of a busy clinic, with other residents and staff present. He asked if I was sure I wanted to do a surgery residency, and he encouraged me to consider other career paths. Thankfully, I did not experience this discrimination from any of my other staff. But I do wonder if there was discrimination of omission...were my male co-residents provided encouragement or advantages that I was not afforded? In my small residency, with a total of 18 residents, we had a total of 5 females during my first year, including another female intern. I felt encouraged that 2/3 of my class was female, but this was the exception and not the rule. Eight years ago, during my surgical residency, I was at a very busy Level 1 trauma center. I can't recall the exact ratio of male to female surgeons, but I know women were in the minority. During a non-emergent trauma case, there was a product representative in the room. During a casual conversation, he was clarifying who was the surgeon. When the senior surgeon in the room (a female), introduced herself, he actually stated "Oh I didn't know women could be trauma surgeons." In an article published in the American Journal of Surgery in 2019, half of all hospitals with emergency general surgery services reported no female surgeons. For the subset of hospitals with EGS services who have an ACS Model, they reported a higher median proportion of women surgeons (17%).(3) Specifically in trauma surgery, women are still under-represented. 28% of surgeons who are board-certified in critical care are female. Thankfully, our voice is gaining strength. More women are going into surgical disciplines, and there are more woman in leadership positions in surgical organizations.(4) 29% of EAST members and 13% of AAST members are female, although there has been an increase in female executive leaders in AAST.(5) "Why should women have to sound like men to get people to listen to them? Why isn't it that everyone in the room should be quiet when she asks for quiet because she is a doctor asking for quiet?" "The theme was clear. Women physicians do not get the same respect men get when dealing with emergencies."(6) Women bring unique strengths to this discipline. It's not a matter of competing to prove that we are superior, but women are inherently different from men and this should be nurtured, not belittled, or ridiculed. Improved communication and patient engagement are just a few of the benefits we can bring to the team. Researchers Find Women Make Better Surgeons Than Men . "The authors attribute the favorable patient outcomes to the female doctors’ ability to communicate and engage with their patients to ensure compliance with medications and therapy, their adeptness at collaborating with colleagues and their tendency to adhere to guidelines when treating patients." This is not a simple problem, and it won't have a simple solution. So what can you do to combat the stereotypes and respectfully establish and maintain your position comparable to your male surgical colleagues? I've learned a few things over the years, with a handful of specific things over the years of my fellowship. Introduce yourself with your Title and name. Previously, I introduced myself as "Christina, part of the surgical team". I regarded my introduction as a display of humility. But I was actually unintentionally undermining my role in the team. I now introduce myself as "Dr ----, one of the trauma surgeons/ acute care surgeons" or "Dr ----, the trauma surgeon/ acute care surgeon who will be taking care of you." Find your team. Seek out mentors, or be a mentor for a younger trainee. Seek support from those who have led the way in this specialty. Get involved. This can be done at all levels, from hospital-level leadership and committee membership, city/ state/ national trauma organizations/ associations Counteract the negative thoughts that can accompany Imposter Syndrome. Keep a list of your strengths and the reason why you chose this specialty. 1. Stamp N. I'm a female surgeon. I feel uncomfortable telling girls they can be one, too. Washington Post. 29 July 2019. 2. McGuire K. Imposter Syndrome: The Dirty Little Secret of Successful Women (And Men Too). Association of Women Surgeons. 3 April 2019. 3. Oslock WM, Paredes AZ, Baselice HE, et al. Women surgeons and the emergence of acute care surgery programs. Am J Surg. 2019;218(4):803-808. 4. Haskins J. Where are all the women in surgery? Association of American Medical Colleges. 15 July 2019. 5. Foster SM, Knight J, Velopulos CG, et al. Gender distribution and leadership trends in trauma surgery societies. Trauma Surg Acute Care Open. 2020;5(1):1-5. 6. Riley, Edward. Voices in the OR: A Self-Reflection and Examination of Unconscious Bias. Doximity. 28 Oct 2020. Previous Next

< Back Chunky Tomato Bisque Ingredients 6 celery ribs, chopped 1 large onion, chopped 1 medium sweet red pepper, chopped 1/4 cup butter, cubed 3 cans (14.5 oz each) diced tomatoes, undrained 1 tablespoon tomato paste 3/4 cup loosely packed basil leaves, coarsely chopped 3 teaspoons sugar 2 teaspoons salt 1/2 teaspoon pepper 1-1/2 cups heavy whipping cream Instructions 1. In a large saucepan, sauté the celery, onion and red pepper in butter for 5-6 minutes or until tender. Add tomatoes and tomato paste. Bring to a boil. Reduce heat; cover and simmer for 40 minutes. 2. Remove from the heat. Stir in the basil, sugar, salt and pepper; cool slightly. 3. Transfer half of the soup mixture to a blender. While processing, gradually add cream; process until pureed. Return to the pan; heat through (do not boil). The vegetables sautéing Previous After blending Dinner is served! Next

< Back Cardiac Physiology Cardiovascular Physiology Oxygen Delivery Adequate cardiovascular function is vital to maintaining perfusion to the organs and tissues in the body. Perfusion drives oxygen delivery (O2) and removal of byproducts of cell metabolism (CO2). The amount of oxygen that is delivered (DO2) is a function of cardiac output (CO; the volume of blood ejected from the heart every minute) and the arterial oxygen content (amount of oxygen in the blood). Cardiac output is determined by the volume of blood the heart pumps out into the body with each heartbeat (stroke volume, SV) and the frequency of the heartbeat (heart rate, HR). Stroke volume depends on preload (blood volume returned to the heart), contractility (effectiveness of cardiac muscle activity), and afterload (pressure in the peripheral vasculature that the heart has to overcome to eject blood). Arterial oxygen content (CaO2) is the amount of O2 in the blood that is ejected from the heart. This is determined by dissolved O2 + O2 bound to hemoglobin. Hemoglobin carries O2, and the percentage of Hgb molecules that are saturated (bound) with O2 is determined by arterial blood gas (SaO2, arterial oxygen concentration) or pulse oximetry (SpO2, peripheral arterial oxygen concentration). Pulse oximetry is non-invasive and is a reliable surrogate (as long as SaO2 >90%). The O2 carrying capacity of one gram of hemoglobin is 1.38 (this is a constant in the equation). So this is the first part of the equation: the number of hemoglobin molecules x the % of those molecules that are saturated with O2 x how much O2 saturated hemoglobin can carry . The second part of the equation is the dissolved oxygen (partial pressure of arterial oxygen, PaO2, reported as mmHg). This value is multiplied by the constant 0.003, which is the mL of O2 dissolved per mmHg plasma. This number is infinitesimally small relative to the other half of the equation and it is typically ignored when determining oxygen concentration. This means that the significant modifiable factor in CaO2 is Hgb. Oxygen has to have something to bind to (Hgb) because dissolved oxygen has minimal oxygen-carrying capacity. Oxygen delivery (DO2)= CO x CaO2 Cardiac Output (CO)= heart rate (HR) x SV Stroke volume (SV)= the volume of blood ejected from the heart each heartbeat. Arterial oxygen concentration (CaO2)= [1.38 x Hgb x SaO2] + [PaO2 x 0.003] How can oxygen delivery be increased? One of the components of the equation has to be adjusted. Increase cardiac output. Increase SV- use of an inotropic agent (* medication that increases the strength of the heart contraction), ensure adequate preload (volume resuscitation). Increase HR- use of a chronotropic agent (* medication that increases heart rate). Increase arterial oxygen content Increase blood hemoglobin concentration *See pharmacology below Oxygen Consumption Oxygen consumption (VO2) is determined by how much oxygen the peripheral tissues extract and use. It is the difference between oxygen delivery (DO2) and oxygen return(ed) (SvO2). Oxygen consumption (VO2)= DO2 - SvO2. Oxygen consumption is calculated by subtracting SvO2 or ScVO2 from the amount of oxygen delivered. Venous oxygen saturation (SvO2 or ScVO2)- concentration of oxygen in the blood returning to the heart. Measured with a central venous catheter. *See below under CV monitoring for more details. Cardiovascular Monitoring There are several techniques for monitoring cardiovascular parameters, ranging from non-invasive to maximally invasive. Non-invasive methods include telemetry, pulse oximetry, and blood pressure monitoring. The benefit of these devices is their simplicity of use and interpretation. But these are error-prone, and regarding blood pressure, it doesn't provide continuous monitoring. For more info, see lecture entitled " Hemodynamics ". Arterial lines can be placed to provide continuous cardiac monitoring. The arterial waveform can indicate specific pathology (see Edwards Quick Guide to Cardiovascular Care ). In addition, an arterial line can report stroke volume variation. Stroke volume variation (SVV) is a surrogate of arterial pressure changes with inspiration/ expiration. If the change in pressure with respiratory cycles is >10-15%, it suggests the patient is fluid responsive, meaning they are likely to improve their preload (and cardiac output and blood pressure) with IV fluid administration. Central venous catheters can be placed to deliver intravenous medication as well as provide cardiac monitoring. A central venous catheter can measure the pressure of the blood returned to the right atrium (central venous pressure, CVP), which is a crude measurement of preload and right heart function. In addition, the oxygenation of the blood returning to the right heart (from the head and upper body) is reported as Central venous oxygenation saturation (ScVO2). ScVO2 reflects the balance between oxygen delivery and consumption. Arterial lines and central venous catheters are considered "minimally invasive". A pulmonary artery (PA) catheter is the most invasive device for cardiac monitoring. Similar to a central venous catheter, a PA catheter can determine the oxygenation of the blood returning to the right heart, which is the mixed venous oxygen saturation (SvO2). However, in contrast to the central venous catheter which is located in the superior vena cava (proximal to the right atria), this device is measuring blood oxygenation in the pulmonary artery (from the right ventricle), so it accounts for the blood from the entire body (unlike the ScVO2). Cardiac Pharmacology Vasoactive medications are frequently used in the ICU for the management of shock, heart failure, and other acute pathology. There are several key receptors, and understanding the function of each receptor is the key to using these different agents correctly. Receptors * α (alpha) 1- vasoconstriction * α2- inhibit norepinephrine release from presynaptic neurons * β (beta) 1- chronotrope (↑HR), inotrope (↑Ca in cardiac myocytes ↑contractility), dromotrope (↑cardiac impulse conduction velocity) * β2- vasodilation * Dopa 1- vasodilation * Dopa 2- neurotransmitter release Pharmacologic Agent Classification Each medication has a specific physiologic effect based on its particular mechanism of action. Agents may stimulate or inhibit receptors (see above) or alter the concentration of a key substance (cAMP, calcium, potassium, nitric oxide (NO)). Previous Next