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< Back Pruritis Ani What is Pruritis Ani? Patient information: Pruritis Ani [American College of Colon and Rectal Surgeons] Pruritis ani is an unpleasant itching of the perianal skin (around the anus). Scratching can lead to further irritation and sets up a vicious cycle. Caused by other anorectal diseases, primary dermatology conditions, hygiene issues (sweat, stool, mucus on the skin), foods, soaps, clothing, or over-vigorous hygiene (aggressive wiping with rough material, use of topical cleaning agents). Diagnosis- detailed history, thorough exam to rule out underlying anorectal pathology What is conservative management for pruritis ani? Try not to scratch/ wipe/ scrub. It will just itch more, and things will get worse. Clean the anal area after bowel movements with hypoallergenic personal wipes. Do NOT over clean, as this may worsen your condition. Dry with a hairdryer on the cool setting instead of wiping the area dry. Use unscented Dove soap or dilute white vinegar for cleansing. AVOID potential contributing factors Citrus foods, caffeine-containing foods/ beverages- coffee, tea, cola, chocolate. Scented soaps, lotions, creams, powders, medicated wipes, witch hazel. Keep the area dry (can use cotton ball or a gauze pad). Avoid tight synthetic clothing that doesn’t breathe. Wear cotton undergarments. Maintain regular bowel movement with normal consistency (minimize stool leakage). Increase stool bulk by increasing fiber intake. Maintain adequate hydration- you MUST drink at least 64 ounces of fluid per day, in addition to increasing fiber intake. Medication Capsaicin- causes a low-grade burning sensation and decreases the perception of itching Zinc oxide- Apply a small amount of a barrier cream to the perianal skin in a thin layer. This will protect the skin from irritants. Mix Benadryl cream with the zinc oxide cream and apply it to the affected area. Benadryl- 25 mg by mouth at night for itching Patient Info- Pruritis Ani .pdf Download PDF • 58KB Patient Info- Fiber Guide .pdf Download PDF • 68KB Previous Next

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

Peer Support < Back Learning how to live with an ostomy Acute Care Surgery can lead to a need for subsequent elective procedures, including ostomy reversals, abdominal wall reconstruction after open abdomen management, and various wounds. I frequently see young, healthy males with ostomies. Thankfully, most patients are great candidates for reversal. But there are a variety of reasons why patients can't undergo reversal, at least not immediately. Injury to the anorectal sphincter complex would put the patient at a very high risk of incontinence. Another possibility is when the ostomy was created in the setting of acute bowel perforation, with an undiagnosed underlying inflammatory process. Reversing an ostomy without further workup could be problematic. I have seen several young, healthy males who have to spend at least a handful of months with their ostomy while undergoing preoperative workup, and more than one who will likely have a prolonged or permanent ostomy. This can be daunting, especially when they were anticipating minimal delay before undergoing a reversal. Common concerns include how to wear normal clothes and how to manage the odor. While I can be supportive, I don't have any first-hand experience of living with an ostomy. One particular patient expressed a desire to return to college, but he was convinced that he couldn’t go to class with an ostomy. Essentially he was resigned to putting his life on hold until his ostomy was reversed. His situation inspired me to seek out a peer who could show him it's possible to live with an ostomy. I reached out to my network of medical personnel that might know how to connect a patient with a peer support group. We have multiple support groups, including trauma survivors, epilepsy, and stroke, to name a few. Unfortunately, I quickly realized there is no group or service to link patients with someone who will answer their questions and hopefully decrease their fears and worries. Many of the trauma patients who have an ostomy are young and healthy, leading active lives. Unlike elective ostomies, such as for inflammatory bowel disease, waking up after trauma with an ostomy is unanticipated and can be very distressing. Also, there is minimal or no chance for preoperative patient education. There is a certain taboo associated with talking about certain bodily functions, and I don't think many young males would ask their trauma surgeon if there is someone they can talk to about having an ostomy. But I think this could be an opportunity to improve the quality of life for a population that is likely overlooked. Previous Next

Accessing the Right Information < Back Confessions of an ICU Physician with a terrible memory Training in medicine starts with textbook learning. But the art of caring for patients can’t be learned in a textbook. Higher-order thinking is essential to understand the interaction between multiple conflicting disease processes, identify nuisances of atypical presentations and find solutions for clinical conundrums. As the field of medicine grows exponentially, the volume of information is too much for one person to keep track of. I find that understanding clinical concepts is much easier than rote memorization of pharmaceutical brand names with their associated generic name, recalling the dose of a paralytic, or identifying the ideal antibiotic for a multi-drug resistant bacteria. After several years of learning and studying mechanical ventilation and how it interacts with and affects a patient's respiratory physiology, I now understand the principles of how to optimize oxygenation and ventilation. As an ICU physician, I can't re-read the basic textbook of mechanical ventilation every time I care for a patient with respiratory failure. I must be able to make decisions relatively quickly and must be able to explain my rationale to residents and bedside nurses while we are working to manage a patient with severe lung disease. But I can pause to look up the recommended dosing of a medication for a patient on dialysis or identify the best anti-microbial for a particular bacteria or fungi. What do I do about important information that I need immediate access to but that doesn't reside in the forefront of my mind? Smartphones, with access to websites and applications , have revolutionized our ability to bring evidence-based medicine to the bedside. Clinical practice guidelines can be accessed on society websites. Deployed Medicine is a resource that provides access to Tactical Combat Casualty Care and Joint Trauma System Clinical Practice Guidelines. There are apps for a wide number of clinical programs that were initially web-based, such as UpToDate. In addition to the resources that are openly available to the public, I have created a database of personal high-yield references. Medication dose ranges, CPGs for our trauma center, AAST Injury Scales, sedation/ pain scores, TEG parameters, and a wide variety of other information that I refer to on a relatively routine basis are now in the palm of my hand. I use the Trello app. I created a dedicated workspace with a group of lists (titles such as trauma, medication, ICU, etc) which each contain multiple individual cards (titles such as A-F bundle, CAM-ICU/ RASS/ CPOT, TEG). I'm not saying you have to use this. But I highly recommend finding a tool that works for you. TL;DR • Take the time to understand processes and concepts- learn one physiology concept from each pt • Have an external tool for storing “rote memorization” facts that you can readily access Previous Next

< Back Appendicitis What is appendicitis? The appendix is a small worm-like structure that hangs from where the small and large bowel connect in your right lower abdomen. It can become inflamed and cause pain. What does surgery entail? What are the risks of the procedure? The surgery to remove your appendix involves using a camera and thin instruments. We typically make 3 incisions- one at your belly button, one right above your pubic bone and one in the left lower abdomen. We divide the appendix with a stapler and remove it. You’ll have a foley in your bladder to help get your bladder out of the way because one of the ports is placed right over the bladder. The folly goes in after you go to sleep and is removed before you wake up. It might burn the first time you pee after surgery. There is a risk of infection following an appendectomy. Bacteria live in the appendix and when we divide it, the bacteria can fall out and form an abscess. This risk is higher if your appendix is ruptured at the time of surgery. This typically presents very similar to appendicitis, because it’s an infection in the same part of your abdomen. Most of the time that can be managed without surgery. We can have our radiology colleagues place a drain into the abscess cavity. What can I expect post-operatively? You will have several small incisions from the laparoscopic port sites. They will have absorbable sutures, nothing that needs to be removed. You will have glue or gauze and paper tape on the incisions. The glue will peel off on its own in 10-14 days. If you have gauze, you can remove this in two days and shower like normal. You will have paper tape strips on the incision, and these will peel off on their own. You are at risk for a hernia through the small incisions, so avoid heavy lifting for 4 weeks after surgery. You may take acetaminophen (Tylenol) and ibuprofen (Motrin) as needed for pain. These can be taken at the same time. Take the narcotic pain medication if your pain is severe despite the acetaminophen and ibuprofen. After the few first days, you should work on decreasing the number of narcotics that you are taking. What can I eat after surgery? There are no specific dietary restrictions. However, if you eat a fatty meal, it may cause loose stool (diarrhea) until your body adjusts to not having your gallbladder, which previously stored the chemicals used to digest fatty food. This is seen in about 10% of patients and usually resolves. If it lasts more than a few weeks, there are medication options to treat this. What should I be worried about after surgery? If you have fever >101 F, severe nausea/ vomiting, inability to tolerate liquids, severe abdominal pain, increasing redness, or drainage from your incisions. Patient Information from Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Appendix Removal (Appendectomy) Surgery American College of Surgeons Appendectomy: Surgical Removal of the Appendix Previous Next

< Back Starting a Business Tips and Tricks from a Novice *Disclaimer* This is all information from my own personal experience. The materials available on this website are for informational purposes only and not to provide legal or financial advice. Please consult a legal or financial expert to obtain advice for any particular issue or problem. TL;DR Choose what type of business entity to start- *research the legislation of your particular state* Register your business name Request EIN Download copies of tax forms Identify NAICS Open business bank account Create template forms- invoice, contract, waiver, receipt, etc Create a spreadsheet for tracking inventory, invoices, payments, etc Save all paperwork and receipts Create standard language for email communication (responses to inquiries, replies to potential clients, advertising messages, etc) and a standard signature block. Maintain consistency- logo, colors, language, font, etc. A few months ago, I embarked on the journey of starting my own business. Before I started this endeavor, I knew very little about business- I knew about limited liability companies (LLC) because my dad has his own LLC. I started my search from scratch, literally googling different derivatives of "business owner". Here's what I found out in my research and while I was creating my own sole proprietorship. There are a few different types of business ownership, including sole proprietorship, partnership, corporations, and limited liability companies (LLC). Specifically, individuals can form an LLC or create a sole proprietorship. These different entities vary based on their reporting requirements, paperwork, etc. Business regulations are not standard nation-wide, so you need to research your state regulations. I eventually decided to proceed with a sole proprietorship. One of the key differences between a sole proprietorship and an LLC is the distinction between the business and the owner. **Remember, it's important to do your research on the laws in your state. ** An LLC theoretically offers more protection- the general principle is that an LLC is separate from the owner. If an LLC is sued, they can't access your personal assets. A sole proprietorship doesn't offer the same boundaries. Sole proprietors have a single owner with complete control over the business, including profits and business decisions, and that individual is also responsible for all debts. The sole proprietorship is not a separate entity from its owner, and therefore it is not taxed separately. In other words, sole proprietors report income and expenses on the proprietor's federal individual income tax. One piece of advice I was given is that an LLC gives more credibility to your business. Personally, I don't think my clientele will be more likely to work with me if I added the designation "LLC" to my business name. In my opinion, given the nature of my business, my medical credentials/ board certification/ degrees are the biggest source of my credibility. MD, FACS, board-certified, etc- these mean something in the medical community. To create a sole proprietorship, I registered my business name and requested a federal employer identification number (EIN). An EIN is not required by the Internal Revenue Service (IRS) for a sole proprietorship- I don't think it's required on my tax forms. However, all the banks I contacted require an EIN to open a business bank account. After registering my business name, I downloaded copies of the tax forms that are required. It helped me understand what would be expected when filing taxes. Much less intimidating than waiting until tax time. Next, I identified my business category as described by the North American Industry Classification System (NAICS). The NAICS is comprised of many categories and sub-categories of business industries, such as construction, utilities, food services, arts and entertainment, real estate, or education. According to the IRS website "NAICS is frequently used for various administrative, regulatory, contracting, taxation, and other non-statistical purposes…Some contracting authorities require businesses to register their NAICS codes, which are used to determine eligibility to bid on certain contracts." Personally, I was required to identify my NAICS when I opened my business bank account. The next step is opening a business bank account. A separate bank account is necessary to distinguish your personal business income from your wages (if you have another job). First, you have to make sure your bank supports business accounts. For anyone who uses USAA for your banking needs, please take note that USAA does NOT support business accounts and you'll need to establish an account with another bank. The process of meeting with a bank manager to set up my bank account was very educational- I learned about the difference between ACH, quick deposit, and wire transfers. Those are the initial steps to having a legitimate business. The next few things help boost your credibility by creating a distinct brand. I initially had one website, which was mostly educational, with a single page for my business. My moniker evolved naturally- docrot was my username in medical school. This eventually morphed into Doc on the Run, which has been my Instagram name for years and became my Twitter handle over a year ago. Initially, my business name was "ABS-CE Prep with Doc on the Run", which was my moniker. Eventually I scaled this back to ABS-CE Prep. While I was still "ABS-CE Prep with Doc on the Run", I decided to make a logo. I used Tailor Brands , which is a user-friendly platform for developing a unique branding and logo. I chose an icon and font to create a simple but distinct logo. Consistency is important. As mentioned in my website creation post, I used the same color scheme for my logo and my website. Using a 6 digit hex code ensures that my blue text and red icon in my logo are the same as the red and blue on my website. Next, depending on your business, you will likely require at least a few standard forms. My business is service-based. I needed a template for invoices and receipts, as well as a standard contract/ waiver to be signed before beginning sessions with a client. Prior to my business name change, I used my logo on each form. Finally, if you still have questions, I recommend consulting a lawyer or business expert. Previous Next

< Back AKI...pending Management of Acute Kidney Injury Previous Next

< Back Sausage Tortellini and Brussels Sprouts Ingredients Sausage Tortellini 2 Tbsp olive oil 2 lbs sausage 2 cloves garlic, minced 1 c vegetable broth 2 c tomato sauce ½ c heavy cream 18 oz tortellini Salt & pepper Brussels Sprouts One package of Brussels Sprouts olive oil black pepper sea salt balsamic vinegar Instructions Sausage Tortellini Heat oil in a large skillet and cook sausage links about 5-7 minutes, until sausages are browned throughout. Add garlic and heat for 30 seconds. Remove sausages from skillet and slice into bite-size pieces. Return sausages to pan along with broth, tomato sauce, cream, and tortellini. Season with salt & pepper. Cover and simmer for 12 minutes. Brussels Sprouts Prepare sprouts by trimming the base and then cutting the sprouts in half or quarters, and then place them in a medium-sized bowl. Drizzle a small amount of olive oil and balsalmic vinegar, and then sprinkle black pepper and sea salt. Toss to coat the sprouts, let sit for at least 30 min. Roast at 400 for 20-30 min, toss halfway through. Sausages cooking Previous Tortellini in Sauce Brussels Sprouts 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 Textbooks General Surgery: Scientific Foundations Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 21st Edition, 2021. This is the detailed explanation of the science behind the practice of surgery. This is the basic science textbook I used during residency. Mulholland and Greenfield's Surgery: Scientific Principles & Practice. Previously known as "Greenfields". General Surgery: Beyond Basic Science Cameron's Current Surgical Therapy. 13th edition, 2019. Short chapters with high-yield information on every topic in General Surgery. Must-have for later in residency. Trauma Mattox Trauma. 9th edition, 2021. The trauma surgery bible. Highly recommend. Critical Care Marino ICU. 4th edition, 2013. The ICU bible. Highly recommend. Civetta, Taylor, & Kirby's Critical Care Medicine. 5th edition, 2017. A detailed explanation of physiology, diagnosis, and management. Finks Critical Care. 7th edition, 2017. Slightly less detailed than Civetta. Excellent book- not too simplistic and not painfully detailed. Evidence-Based Practice of Critical Care. 3rd edition, 2019. Reviews the literature regarding specific high yield critical care topics. Surgical Critical Care Therapy: A Clinically Oriented Practical Approach. 1st edition, 2018. Essentials of Mechanical Ventilation. 4th edition, 2018. 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