Podcasts about emergency general surgery

It is the final episode of our Challenging Cases in Emergency General Surgery series and we're diving into another dreaded topic: the complex abdominal wall. This structure is a daily partner to the general surgeon—but when things go wrong, it can quickly become our biggest challenge. In this episode, we'll walk through the emergency presentation of a patient with multiple prior hernia repairs and mesh placements, and how these complicate diagnosis and management. From imaging pearls to OR decision-making and post-op dilemmas, this episode covers it all.  We round things off with a fun game (as always!) and some hot takes on abdominal wall strategies in emergency general surgery. Whether you're an EGS surgeon, trainee, or surgical enthusiast, this episode is packed with practical insights, decision-making frameworks, and real-world nuance. Hosts: - Dr. Ashlie Nadler - Dr. Jordan Nantais - Dr. Graham Skelhorne-Gross Learning Objectives: - Identify key factors to assess in patients presenting with complex abdominal wall problems, including detailed surgical history, hernia characteristics, and signs of complications. - Discuss the role of imaging, particularly CT scans, in evaluating patients with ventral hernias and bowel obstruction, with a focus on identifying transition points and signs of strangulation. - Outline the surgical approach to incarcerated incisional ventral hernias, including pre-operative considerations, operative techniques, and management of threatened bowel. - Recognize the importance of patient-specific factors and interdisciplinary collaboration in the management of complex abdominal wall cases, including the role of pre-habilitation and hernia specialists. Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out our recent episodes here: https://app.behindtheknife.org/listen

In this episode, Tom Varghese, MD, FACS, is joined by Haytham Kaafarani, MD, MPH, FACS, and Vahe Panossian, MD, from the Department of Surgery, Massachusetts General Hospital and Harvard Medical School. They discuss the recent article by Drs Kaafarani and Panossian, “Validation of Artificial Intelligence-Based POTTER Calculator in Emergency General Surgery Patients Undergoing Laparotomy: Prospective, Bi-Institutional Study.” This study found that POTTER accurately predicts mortality and postoperative complication, and the superior accuracy, user-friendliness, and interpretability of POTTER make it a useful bedside tool for preoperative counseling.    Disclosure Information: Drs Varghese and Panossian have nothing to disclose. Dr Kaafarani receives honoraria payments from UpToDate. The POTTER calculator is available online for free, and Dr Kaafarani has not been compensated for the development or ongoing use of the calculator.  To earn 0.25 AMA PRA Category 1 Credits™ for this episode of the JACS Operative Word Podcast, click here to register for the course and complete the evaluation. Listeners can earn CME credit for this podcast for up to 2 years after the original air date. Learn more about the Journal of the American College of Surgeons, a monthly peer-reviewed journal publishing original contributions on all aspects of surgery, including scientific articles, collective reviews, experimental investigations, and more. #JACSOperativeWord

In this episode by the Emergency General Surgery team, we explore the inevitable in acute care surgery- complications. Once a taboo subject, we are now beginning to understand how surgeons and care teams are affected when things don't go as planned. The team discusses two articles that explore the impact of surgical complications on surgeons, both in the short and long term, as well as ways to rehabilitate and support surgeons when they face a challenging complication. Drawing on the article, as well as personal experience, this episode works towards the ongoing shift in surgical culture around outcomes and supports improved surgeon wellness.  Hosts Dr. Ashlie Nadler Dr. Jordan Nantais,  Dr. Graham Skelhorne-Gross Dr. Marika Sevigny References Zhu A, Deng S, Greene B, Tsang M, Palter VN, Jayaraman S. Helping the Surgeon Recover: Peer-to-Peer Coaching after Bile Duct Injury. J Am Coll Surg. 2021 Aug;233(2):213-222.e1. doi: 10.1016/j.jamcollsurg.2021.05.011. Epub 2021 Jun 7. PMID: 34111530. https://pubmed.ncbi.nlm.nih.gov/34111530/ Han K, Bohnen JD, Peponis T, Martinez M, Nandan A, Yeh DD, Lee J, Demoya M, Velmahos G, Kaafarani HMA. The Surgeon as the Second Victim? Results of the Boston Intraoperative Adverse Events Surgeons' Attitude (BISA) Study. J Am Coll Surg. 2017 Jun;224(6):1048-1056. doi: 10.1016/j.jamcollsurg.2016.12.039. Epub 2017 Jan 16. PMID: 28093300. https://pubmed.ncbi.nlm.nih.gov/28093300/ Learning objectives Understand the psychological impact of surgical complications on the care provider Explore the role of peer-to-peer mentoring in support and rehabilitation of surgeons Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out our recent episodes here: https://app.behindtheknife.org/listen

Joseph Sakran, MD, MPH was a teenager in a small town in Virginia when, in 1994, his life took a dramatic turn. At the age of 17, he was out with his friends after a high school football game when a nearby gunfight broke out and he was struck by a stray bullet in the throat. The bullet, tearing through his windpipe and a carotid artery, brought him to the razor edge of death before he was saved by trauma surgeons. Thirty years later, Dr. Sakran is now a trauma surgeon who serves as Director of Emergency General Surgery at the Johns Hopkins Hospital in Baltimore and a vocal advocate of reducing firearm injury through public health initiatives at the state and national levels. Following the 2018 comment by the National Rifle Association that doctors should “stay in their lane” with regard to gun violence prevention, Dr. Sakran started the #ThisIsOurLane movement, mobilizing thousands of health care professionals to advocate for gun violence as a public health crisis. Over the course of our conversation, Dr. Sakran shares his harrowing experience of being shot and what it was like to be confronted with imminent death, how his perspectives on and priorities in life changed after the incident, what goes on in his mind when he operates on victims of gun violence, how he connects with his patients over shared experiences of trauma, how all clinicians can be more empathetic with their patients, and why advocacy is integral to the work of a physician. In this episode, you'll hear about: 2:46 - How a personal tragedy set Dr. Sakran on the path to becoming a trauma surgeon 9:51 - How Dr. Sakran's perspective on life was altered by his personal experience with gun violence13:11 - How Dr. Sakran's experiences informs his approach to speaking with patients and their loved ones during traumatic situations 19:09 - The importance of showing empathy to build rapport with patients and families23:51 - What it is like to tend to victims of violence 29:26 - Addressing the public health crisis of gun violence in America 37:41 - How clinicians can become more involved in advocacy45:32 - Dr. Sakran's advice to future clinicians Dr. Joseph Sakran can be found on Twitter/X at @josephsakran.Visit our website www.TheDoctorsArt.com where you can find transcripts of all episodes.If you enjoyed this episode, please subscribe, rate, and review our show, available for free on Spotify, Apple Podcasts, or wherever you get your podcasts. If you know of a doctor, patient, or anyone working in health care who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments or send an email to info@thedoctorsart.com.Copyright The Doctor's Art Podcast 2024

Join our Emergency General Surgery team as we talk about the dreaded difficult duodenum. We discuss two cases on a common disease that has now become a rarity in surgical management. We cover principles of combined assessment and resuscitation, diagnosis and helpful adjuncts, and multidisciplinary and surgical management. Hosts: Drs. Ashlie Nadler, Jordan Nantais and Graham Skelhorne-Gross We have come a long way from managing duodenal emergencies with vagotomies since the widespread use of proton pump inhibitors. But surgeons and trainees still need to gain competence in managing duodenal emergencies, despite the dearth of operative interventions often encountered. We discuss the two most common presentations related to duodenal ulcers - bleeding and perforation. We focus on resuscitation, damage-control surgery, and the role of non-surgical management options.  Learning Objectives: - Learn to investigate and resuscitate patients with upper gastrointestinal bleeding - Develop an approach to the management of upper gastrointestinal bleeding - Understand the risks and benefits of various surgical techniques for dealing with perforated duodenal ulcers References:  Tarasconi, A., Coccolini, F., Biffl, W.L. et al. Perforated and bleeding peptic ulcer: WSES guidelines. World J Emerg Surg 15, 3 (2020). https://doi.org/10.1186/s13017-019-0283-9 Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out our recent episodes here: https://app.behindtheknife.org/listen

Can appendicitis wait until the morning? Join Drs. Ashlie Nadler, Jordan Nantais, Graham Skelhorne-Gross, and Marika Sevigny from our Emergency General Surgery Team as they discuss the role of deferring appendectomies from overnight to the next morning. Paper 1: Patel SV, Zhang L, Mir ZM, Lemke M, Leeper WR, Allen LJ, Walser E, Vogt K. Delayed Versus Early Laparoscopic Appendectomy for Adult Patients With Acute Appendicitis: A Randomized Controlled Trial. Ann Surg. 2024 Jan 1;279(1):88-93. https://pubmed.ncbi.nlm.nih.gov/37436871/ -Non-inferiority randomized controlled trial comparing delayed appendectomy group with surgery taking place after 0600 the morning following a decision to operate versus the immediate appendectomy group with surgery taking place between 8pm and 4am and within 6 hours of a decision to operate -A priori non-inferiority margin of 15% for 30-day complications -Intention-to-treat analysis with risk difference -12% in favor of the delayed group (p < 0.001) -Superiority as on per protocol analysis -Underpowered at 91% due to early closure of study due to loss of reliable day time emergency triage operating time Paper 2: Jalava K, Sallinen V, Lampela H, Malmi H, Steinholt I, Augestad KM, Leppäniemi A, Mentula P. Role of preoperative in-hospital delay on appendiceal perforation while awaiting appendicectomy (PERFECT): a Nordic, pragmatic, open-label, multicentre, non-inferiority, randomised controlled trial. Lancet. 2023 Oct 28;402(10412):1552-1561. https://pubmed.ncbi.nlm.nih.gov/37717589/ -Non-inferiority randomized controlled trial comparing appendectomy within 8 hours versus 24 hours -No difference in rate of perforation on intention-to-treat or per protocol analyses Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  If you liked this episode, check out more recent episodes: https://app.behindtheknife.org/listen

Join our Emergency General Surgery team as we talk about a popular and controversial issue in surgery: dealing with complicated cases in pancreatitis. We discuss two hard-hitting cases and cover principles of diagnosis, early management and disposition, and things to look out for every step of the way. We cover some common and some rare but particularly problematic complications. Although there is no right answer to every case of pancreatitis, we try to help learners to develop an approach to pancreatitis that considers the morbidity and benefits of every option. Hosts: Drs. Ashlie Nadler, Jordan Nantais and Graham Skelhorne-Gross Learning Objectives: - Review the diagnostic criteria for acute pancreatitis - Learn to anticipate common and major complications of acute pancreatitis - Develop an approach to complications of pancreatitis accounting for patient, family, practitioner, and institutional factors - Understand the risks and benefits of various methods for dealing with pancreatic necrosis and infection TENSION trial https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32404-2/fulltext MISER trial https://pubmed.ncbi.nlm.nih.gov/30452918/ Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out other emergency general surgery episodes here: https://behindtheknife.org/podcast-category/emergency-general-surgery/

An ever-present spectre looming over the hearts of general surgeons everywhere! Please join our Emergency General Surgery team for a journal review about Clostridium difficile (C. diff) infection. Dr. Ashlie Nadler and Dr. Jordan Nantais are joined by guest Dr. Marika Sevigny, recent graduate of trauma and acute care surgery at the University of Toronto, as Dr. Graham Skelhorne-Gross prepares for his upcoming fellowship at Harborview. Paper 1: Ahmed et al. Risk factors of surgical mortality in patients with Clostridium difficile colitis. A novel scoring system. Eur J Trauma Emerg Surg. 2022 Jun. - Risk score development study using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) - 525 adult (18-89) patients undergoing colectomy between 2012 and 2016 - Split data into training (80%) and testing (20%) datasets -  Identified mortality risk factors to create and validate a scoring system - Scores ranged from 0 to 37 with the highest score predicting an 83.9% risk of mortality - This scoring system appears relatively straight-forward and methodically sound but the lack of a currently available calculator limits use to some degree Paper 2: McKechnie et al. Total Abdominal Colectomy Versus Diverting Loop Ileostomy and Antegrade Colonic Lavage for Fulminant Clostridioides Colitis: Analysis of the National Inpatient Sample 2016-2019. J Gastrointest Surg. 2023 Apr 20. - Retrospective cohort study of adults (18+) in the National Inpatient Sample (NIS) admitted between Jan 2016 and Dec 2019 for C. difficile colitis, undergoing either a total abdominal colectomy (TAC) or diverting loop ileostomy (DLI) with antegrade vancomycin enemas - Focus on not only mortality and complications but also admission cost and length of stay - 886 TAC and 409 DLI patients were identified - Multivariable logistic regression analysis showed no difference in mortality or overall complications - TAC patients had shorter admissions (mean difference 4.06 days) and lower cost (mean difference $79,715.34) - Study was limited as it considered only the initial admission and is unable to provide data on outcomes and costs beyond this time - Furthermore, there is consideration for disease severity in the analysis, which may impede the ability to compare the two operative approaches Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out our other Emergency General Surgery episodes here: https://behindtheknife.org/podcast-category/emergency-general-surgery/

Have you transitioned a portion of your practice to the robot, but would be hesitant to book an urgent/call case on the robot? Have you wondered if the robot might be useful in your emergency or acute care surgery practice? Join University of Washington MIS Surgeons, Drs. Andrew Wright, Nicole White, and Nick Cetrulo, and Resident Drs. Ben Vierra and Paul Herman as they discuss the growing use of the robot for acute cases and provide tips on appropriate case selection.  Hosts:  1.     Andrew Wright, UW Medical Center – Montlake and Northwest, @andrewswright  2.     Nick Cetrulo, UW Medical Center - Northwest, @Trules25  3.     Nicole White, UW Medical Center - Northwest  4.     Paul Herman, UW General Surgery Resident PGY-3, @paul_herm  5.     Ben Vierra, UW General Surgery Resident PGY-2  Learning objectives:   - Describe the importance of the MIS approach in EGS  - Review 3 articles on robotic EGS outcomes  1) Robotic surgery in emergency setting: 2021 WSES position paper  2) Emergent robotic versus laparoscopic surgery for perforated gastrojejunal ulcers: a retrospective cohort study of 44 patients  3) Urgent robotic subtotal colectomy for severe acute ulcerative colitis has comparable periop outcomes to laparoscopic surgery  - Discuss factors influencing appropriate case selection for urgent/emergent robotic cases  - Discuss value as it pertains to robotic EGS  References  1.     Havens JM, Peetz AB, Do WS, Cooper Z, Kelly E, Askari R, Reznor G, Salim A. The excess morbidity and mortality of emergency general surgery. J Trauma Acute Care Surg. 2015 Feb;78(2):306-11. doi: 10.1097/TA.0000000000000517. PMID: 25757115.  2.     Scott JW, Olufajo OA, Brat GA, Rose JA, Zogg CK, Haider AH, Salim A, Havens JM. Use of National Burden to Define Operative Emergency General Surgery. JAMA Surg. 2016 Jun 15;151(6):e160480. doi: 10.1001/jamasurg.2016.0480. Epub 2016 Jun 15. PMID: 27120712.   3.     Arnold M, Elhage S, Schiffern L, Lauren Paton B, Ross SW, Matthews BD, Reinke CE. Use of minimally invasive surgery in emergency general surgery procedures. Surg Endosc. 2020 May;34(5):2258-2265. doi: 10.1007/s00464-019-07016-1. Epub 2019 Aug 6. PMID: 31388806.  4.     Sheetz KH, Claflin J, Dimick JB. Trends in the Adoption of Robotic Surgery for Common Surgical Procedures. JAMA Netw Open. 2020 Jan 3;3(1):e1918911. doi: 10.1001/jamanetworkopen.2019.18911. PMID: 31922557; PMCID: PMC6991252.   5.     de'Angelis N, Khan J, Marchegiani F, Bianchi G, Aisoni F, Alberti D, Ansaloni L, Biffl W, Chiara O, Ceccarelli G, Coccolini F, Cicuttin E, D'Hondt M, Di Saverio S, Diana M, De Simone B, Espin-Basany E, Fichtner-Feigl S, Kashuk J, Kouwenhoven E, Leppaniemi A, Beghdadi N, Memeo R, Milone M, Moore E, Peitzmann A, Pessaux P, Pikoulis M, Pisano M, Ris F, Sartelli M, Spinoglio G, Sugrue M, Tan E, Gavriilidis P, Weber D, Kluger Y, Catena F. Robotic surgery in emergency setting: 2021 WSES position paper. World J Emerg Surg. 2022 Jan 20;17(1):4. doi: 10.1186/s13017-022-00410-6. PMID: 35057836; PMCID: PMC8781145.   6.     Robinson TD, Sheehan JC, Patel PB, Marthy AG, Zaman JA, Singh TP. Emergent robotic versus laparoscopic surgery for perforated gastrojejunal ulcers: a retrospective cohort study of 44 patients. Surg Endosc. 2022 Feb;36(2):1573-1577. doi: 10.1007/s00464-021-08447-5. Epub 2021 Mar 24. PMID: 33760973.   7.     Anderson M, Lynn P, Aydinli HH, Schwartzberg D, Bernstein M, Grucela A. Early experience with urgent robotic subtotal colectomy for severe acute ulcerative colitis has comparable perioperative outcomes to laparoscopic surgery. J Robot Surg. 2020 Apr;14(2):249-253. doi: 10.1007/s11701-019-00968-5. Epub 2019 May 10. PMID: 31076952.  8.     Gangemi A, Danilkowicz R, Bianco F, Masrur M, Giulianotti PC. Risk Factors for Open Conversion in Minimally Invasive Cholecystectomy. JSLS. 2017 Oct-Dec;21(4):e2017.00062. doi: 10.4293/JSLS.2017.00062. PMID: 29238153; PMCID: PMC5714218.  9.     Bhama AR, Wafa AM, Ferraro J, Collins SD, Mullard AJ, Vandewarker JF, Krapohl G, Byrn JC, Cleary RK. Comparison of Risk Factors for Unplanned Conversion from Laparoscopic and Robotic to Open Colorectal Surgery Using the Michigan Surgical Quality Collaborative (MSQC) Database. J Gastrointest Surg. 2016 Jun;20(6):1223-30. doi: 10.1007/s11605-016-3090-6. Epub 2016 Feb 3. PMID: 26847352.  10.   https://www.east.org/about-east/news-and-events/news/details/320/east-robotic-surgery-for-the-acute-care-surgeon-webinar-series Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out other MIS episodes here: https://behindtheknife.org/podcast-category/minimally-invasive/

Please join Drs. Graham Skelhorne-Gross, Jordan Nantais and Ashlie Nadler from our Emergency General Surgery Team for a discussion on cirrhotic patients.   Child-Pugh Score (https://www.mdcalc.com/calc/340/child-pugh-score-cirrhosis-mortality) ·      Bilirubin, albumin, INR, ascites, encephalopathy ·      Used to predict operative mortality based on cirrhosis severity ·      Mortality in EGS: - Child-Pugh A: 10% electively and 22% emergently - Child-Pugh B: 30% electively and 38% emergently - Child-Pugh C: 80% electively and up to 100% emergently Model for End Stage Liver Disease (MELD) (https://www.mdcalc.com/calc/10437/model-end-stage-liver-disease-meld?utm_source=site&utm_medium=link&utm_campaign=meld_12_and_older) ·      creatinine, bilirubin, INR, and sodium ·      MELD < 20 – 1% increase in mortality with each point increase ·      MELD > 20 – 2% increase in mortality with each point increase Pre-operative Planning ·      Identification of cirrhosis with physical examination, bloodwork and imaging ·      Involvement of other medical services (internal medicine, hepatology, ICU) as needed ·      Cirrhosis optimization, if possible ·      Abdominal wall mapping Unexpected Intraoperative Finding Communicate unexpected findings to the operative team and think of additional adjuncts you may need such as additional ports, topical hemostatic agents or energy devices. Think about why you are in the OR. If its an elective situation and can wait, consider bailing. If its emergent, you may have to do something more definitive. Exposure may be a challenge, you may have to alter your typical approach including where the assistant grabs and retracts. Extra hands are helpful. Bleeding can be a big deal. If possible, map out the abdominal wall ahead of time with cross-sectional imaging. Stay away from varices around the umbilicus or porta Ventral Hernia + Cirrhosis ·      Ideally, control ascites pre-operatively, if you can't consider leaving drains ·      Small (< 2cm) hernias close primarily ·      Larger (>2cm) hernias repair with mesh unless infected filed (controversial) ·      Minimally invasive repairs can be performed Benign Biliary Disease + Cirrhosis ·      Incidence of gallstones is 4-5 times higher in cirrhotic patients ·      Prophylactic laparoscopic cholecystectomy (LC) generally not done ·      LC generally considered acceptable in CP A or B but not C (exceptions: HD instability, gangrenous cholecystitis, hemorrhagic cholecystitis) ·      Cholecystostomy and ERCP are safe References:  Bleszynski, M. et. Al. Acute care and emergency general surgery in patients with chronic liver disease: how can be optimize perioperative care? A review of the literature. 2018. World Journal of Emergency Surgery; 13:32 Mansour A, Watson W, Shayani V, et al. Abdominal operations in patients with cirrhosis: still a major surgical challenge. Surgery. 1997;122:730–5. Yeom SK, Lee CH, Cha SH, Park CM. Prediction of liver cirrhosis, using diagnostic imaging tools. World J Hepatol. 2015 Aug 18;7(17):2069-79. doi: 10.4254/wjh.v7.i17.2069. PMID: 26301049; PMCID: PMC4539400. Jain D, Mahmood E, V-Bandres M, Feyssa E. Preoperative elective transjugular intrahepatic portosystemic shunt for cirrhotic patients undergoing abdominal surgery. Ann Gastroenterol. 2018 May-Jun;31(3):330-337. doi: 10.20524/aog.2018.0249. Epub 2018 Mar 15. PMID: 29720858; PMCID: PMC5924855. **Fellowship application link: https://forms.gle/PiKM2MMQpE5jSAeW7 Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out other Emergency General Surgery episode here: https://behindtheknife.org/podcast-category/emergency-general-surgery/

Did you miss this year's Eastern Association for the Surgery of Trauma meeting?  Don't sweat it!  Behind the Knife has got you covered.  In this episode we discuss “Scientific Papers that Should Change Your Practice” with EAST manuscript and literature committee members Drs. Laura Brown (@laurarbrownMD), Brittany Bankhead (@bbankheadMD), and Julia Coleman (@juliacolemanMD).   Universal blunt cerebrovascular screening?  Early renal replacement therapy?  Artificial intelligence in emergency general surgery?  This episode is PACKED with high-yield material.   To learn more about all the good things happening at EAST visit www.east.org.  Papers discussed:  1.     Do not forget the platelets: The independent impact of red blood cell to platelet ratio on mortality in massively transfused trauma patients (https://pubmed.ncbi.nlm.nih.gov/35313325/) 2.     The 35-mm rule to guide pneumothorax management: Increases appropriate observation and decreases unnecessary chest tubes (https://pubmed.ncbi.nlm.nih.gov/35125448/) 3.     Timing of thromboprophylaxis in patients with blunt abdominal solid organ injuries undergoing nonoperative management (https://pubmed.ncbi.nlm.nih.gov/33048907/) 4.     Universal screening for blunt cerebrovascular injury (https://pubmed.ncbi.nlm.nih.gov/33502144/) 5.     A three-step support strategy for relatives of patients during in the intensive care unit: a cluster randomized trial (https://pubmed.ncbi.nlm.nih.gov/35065008/) 6.     Hypothermia versus Normothermia after Out-of-Hospital Cardiac Arrest (https://pubmed.ncbi.nlm.nih.gov/34133859/) 7.     Timing of Initiation of Renal-Replacement Therapy in Acute Kidney Injury (https://pubmed.ncbi.nlm.nih.gov/32668114/) 8.     Disparities in Spatial Access to Emergency Surgical Services in the US (https://pubmed.ncbi.nlm.nih.gov/36239953/) 9.     Validation of the AI-based Predictive Optimal Trees in Emergency Surgery Risk (POTTER) Calculator in Patients 65 Years and Older (https://pubmed.ncbi.nlm.nih.gov/33378309/) 10.  Accuracy of Risk Estimation for Surgeons Versus Risk Calculators in Emergency General Surgery (https://pubmed.ncbi.nlm.nih.gov/35594615/) **Specialty team application link - https://forms.gle/DwrRcMYDaP3a3LaQA Please email hello@behindtheknife.org with any questions. Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out other trauma episodes here: https://behindtheknife.org/podcast-category/trauma/

The dreaded Surgical Site Complications! Join Drs. Ashlie Nadler, Jordan Nantais and Graham Skelhorne-Gross from our Emergency General Surgery Team as they discuss surgical site complications and prevention techniques. Paper 1: Arnold et. al. (2019) Not a Routine Case, Why Expect the Routine Outcome? Quantifying the Infectious Burden of Emergency General Surgery Using the NSQIP. American Surgeon  - NSQIP database 2005-2016 (>800,000 patients) including open/laparoscopic cholecystectomies, ventral hernia repairs, and partial colectomies  - Comparing outcomes in emergent vs elective cases - Primary outcome: aggregate of SSIs which includes wound disruption, superficial SSI, deep SSI, and organ space SSI  - Results: -- ↑SSI in the emergency group (5.3% vs 3.6%)  -- When controlling for multiple variables, emergency surgery associated with more SSIs (OR 1.15).   Paper 2: Lakhani et. al. (2022) Prophylactic negative pressure wound dressings reduces wound complications following emergency laparotomies: A systematic review and meta-analysis. Surgery  - NPWD remove excess fluid from subcutaneous space, ↓ collections/contaminants, promote angiogenesis, fibroblast infiltration   - Literature review 2005-2022 (NPWD, laparotomy, SSI)  - 1199 patients included (566 NPWD, 633 standard dressings)  - Results: -- NPWD ↓ wound infection (OR 0.43) and wound breakdown (OR 0.36)  -- No change in LOS, readmission Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out other Emergency General Surgery episodes here: https://behindtheknife.org/podcast-category/emergency-general-surgery/ 

In this episode, Dr. Yeh is joined by Claire Rosen, MD, from the Hospital of the University of Pennsylvania. They discuss her recent paper, which demonstrates that past medical history, specifically multimorbidity, influences the risk of adverse outcomes after emergency general surgery, from increased mortality to limited independence and function. When surgeons understand and communicate these risks, shared decision making is improved. Learn more about the Journal of the American College of Surgeons, a monthly peer-reviewed journal publishing original contributions on all aspects of surgery, including scientific articles, collective reviews, experimental investigations, and more. #JACSOperativeWord

We Need To Talk Breast Cancer Welcome to our special We Need To Talk series - We Need To Talk Breast Cancer, in light of Breast Cancer Awareness Month. These episodes are hosted by Pink Ribbon Ambassador and Coast Day show announcer Lorna Subritzky. Lorna is currently undergoing treatment for her second breast cancer diagnosis.  In this episode, Lorna chats to Michael Puttick. Michael is a General Surgeon with special interests in Breast Surgery and Emergency General Surgery. This episode covers the importance of surgery in breast cancer recovery.See omnystudio.com/listener for privacy information.

Join Dr. Carrie Valdez as she discusses the EAST MCT on Outcomes after Emergency General Surgery and Trauma Care in Incarcerated Individuals with authors Drs. MK Bryant, Liz Dreesen, Sara Scarlet and Rebecca Maine.  Learn about outcomes, working with your IRB, and what you can do to increase ethical and compassionate care. Supplemental MaterialOutcomes after emergency general surgery and trauma care in incarcerated individuals: An EAST multicenter study. Bryant MK, Tatebe LC, Rajaram S, Udekwu PO, Wurzelmann M, Crandall ML, Zuniga YD, Tran V, Santos A, Krause C, et al. J Trauma Acute Care Surg. 2022 Jul 1;93(1):75-83.

Join our Emergency General Surgery team as they discuss Necrotizing Soft-Tissue Infections. Hosted by Drs. Jordan Nantais, Ashlie Nadler, Stephanie Mason and Graham Skelhorne-Gross. Necrotizing Soft-Tissue Infections: - Also known as “flesh eating disease”, gas gangrene, necrotizing fasciitis/myositis, Fournier's gangrene.  - Early findings are non-specific - Rapidly fatal - diagnostic delay can lead to tremendous additional morbidity and mortality Classification: - Type 1 - polymicrobial category (most common) found in immunosuppressed or elderly - Type 2 - monomicrobial infection [Group A Streptococcus > Methicillin-resistant Staphylococcus aureus (MRSA)] - Type 3 - monomicrobial infection (Vibrio or Clostridium) - Type 4 - fungal (rare) in immunocompromised or after penetration or trauma from candida or Zygomycetes. Initial Workup - History: (comorbidities, immunosuppression, recent infections or trauma) - Exam: swelling, open lesions, drainage, erythema, crepitus, and pain out of proportion      - Most common: swelling, pain, erythema      - Bullae, skin necrosis, crepitus are less common - Labs: Hb, wbc, Na, Creat, glucose, and CRP - Imaging: CT, MRI *sensitive and specific but may not change management - Cut-down: bedside vs in OR - Gm stain  Management - Initially: two large bore IVs, foley catheter, aggressive fluid resuscitation, broad spectrum antibiotics, vasopressors PRN - Abx choices: carbopenem or piperacllin-tazobactam or cefotaxime plus metronidazole. Clindamycin (antitoxin effect) and vancomycin (MRSA) should be considered. - OR: must debride all dead/infected tissue, involve other surgical specialties as needed      - Mark edge of cellulitis and use as initial debridement      - Healthy dermis – pearly and white      - Healthy fat – pale, yellow, glistening      - Healthy fascia – should bleed, doesn't easily separate from muscle      - Healthy muscle – contract with cautery      - Dressing: betadine-soaked gauze on the wound      - Most patients will need at least 3 ORs (second OR generally 8-12 hours after the first)      - No VAC or stoma at first OR References:  1.    Pelletier J, Gottlieb M, Long B, Perkins JC Jr. Necrotizing Soft Tissue Infections (NSTI): Pearls and Pitfalls for the Emergency Clinician. J Emerg Med. 2022 Apr;62(4):480-491. doi: 10.1016/j.jemermed.2021.12.012. Epub 2022 Jan 31.  2.    Sarani B, Strong M, Pascual J, Schwab CW. Necrotizing fasciitis: current concepts and review of the literature. J Am Coll Surg. 2009 Feb;208(2):279-88.  3.    Edlich RF, Cross CL, Dahlstrom JJ, Long WB 3rd. Modern concepts of the diagnosis and treatment of necrotizing fasciitis. J Emerg Med. 2010 Aug;39(2):261-5 4.    Hoesl V, Kempa S, Prantl L, Ochsenbauer K, Hoesl J, Kehrer A, Bosselmann T. The LRINEC Score-An Indicator for the Course and Prognosis of Necrotizing Fasciitis? J Clin Med. 2022 Jun 22;11(13):3583 5.    Bulger EM, May A, Bernard A, Cohn S, Evans DC, Henry S, Quick J, Kobayashi L, Foster K, Duane TM, Sawyer RG, Kellum JA, Maung A, Maislin G, Smith DD, Segalovich I, Dankner W, Shirvan A. Impact and Progression of Organ Dysfunction in Patients with Necrotizing Soft Tissue Infections: A Multicenter Study. Surg Infect (Larchmt). 2015 Dec;16(6):694-701. 6.    LRINEC Score from: https://www.mdcalc.com/calc/1734/lrinec-score-necrotizing-soft-tissue-infection#:~:text=Patients%20were%20classified%20into%20three,%25%20and%20NPV%20of%2096%25. Retrieved July 2022. If you liked this episode, check out our recent episode titled, "Journal Review in Colorectal Surgery: Timing of Biologics and Surgery in the Setting of Crohn's Disease" which can be found here. Please visit behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

No more thoughts and prayers. Grieving Americans are demanding gun control after the worst school shooting in the US in a decade. But Congress has repeatedly failed to pass tougher laws. So, what's stopping action to prevent another tragedy? Join host Mohammed Jamjoom. Guests: Joseph Sakran - gun violence survivor and Director of Emergency General Surgery at Johns Hopkins Hospital. Jocelyn Sage Mitchell - Professor of American and Comparative Politics, Northwestern University in Qatar. Richard Feldman - Former Regional Political Director at the National Rifle Association.

Created in coordination with the EAST Rural Trauma Committee. Drs. Lauren Dudas and Michal Radomski discuss Emergency General Surgery (EGS) with rural providers Dr. Nicholas Bandy, Dr. Kristin Colling & Dr. Keelin Roche.  Listen to hear about rural practice models, procedures important to become comfortable with as rural providers, a bit about organizing an EGS service, and considerations for pursuing a career in rural surgery.

Drs. Zeev Kain and Timothy Stephens discuss the article “What Influences the Effectiveness of Quality Improvement in Perioperative Care: Learning From Large Multicenter Studies in Emergency General Surgery?” published in the March 2022 issue of Anesthesia & Analgesia.

Join our Emergency General Surgery Team as they discuss EGS in patients > 65.  Introduction - > 65 = 40% of EGS admissions  - In-hospital mortality for EGS in older adults is approximately 7-12% and the one-year mortality is around 30-38%. - High risk due to decreased reserve, poor nutritional status, and chronic medical conditions  - Frailty correlates with poor post-operative outcomes Paper #1: Mehta A, Dultz LA, Joseph B, Canner JK, Stevens K, Jones C, Haut ER, Efron DT, Sakran JV. Emergency general surgery in geriatric patients: A statewide analysis of surgeon and hospital volume with outcomes. J Trauma Acute Care Surg. 2018 Jun;84(6):864-875.  - retrospective population-based cross-sectional study using administrative data.  - looks at the association between surgeon and hospital annual experience with outcomes in geriatric patients with EGS conditions. - Note Table 2 provides outcomes broken down by type of surgery - Key finding: patients operated on by a low-volume surgeon had about twice the odds of mortality, and 1.7X the odds of failure to rescue Paper #2: Guttman MP, Tillmann BW, Nathens AB, Saskin R, Bronskill SE, Huang A, Haas B. Alive and at home: Five-year outcomes in older adults following emergency general surgery. J Trauma Acute Care Surg. 2021 Feb 1;90(2):287-295.  - large-scale population-based retrospective cohort study looking at long-term outcomes of older adults with admissions for emergency general surgery diagnoses - primary outcome of interest is “aging in place” or being able to reside in one's home for as long as possible.  - Key finding: being admitted for an EGS diagnosis reduces your survival and time in your home by about 7 months. - Very little reduction in low-risk diagnoses (acute appendicitis/cholecystitis) - 57% of patients were alive and in their home 5 years later Please visit behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

When we think about regionalization of care, particularly in the setting of trauma, we often think about triage being done from a lower to a higher tier center. Today on the show we are joined by Dr. Maria Baimas-George to hear about the benefits of doing things the other way round. Dr. Baimas-George is currently a PGY 4 categorical general surgery resident at Carolinas Medical Center Atrium Health in Charlotte, North Carolina. She has been very active from a research and publication standpoint, and her recent paper, ‘Emergency general surgery transfer to lower acuity facility: The role of right-sizing care in EGS regionalization' was selected as the best of EGS paper for the JTACS 2022 January edition. In this paper, Dr. Baimas-George evaluates a 16-month experience of a five-surgeon team triaging EGS patients at Carolinas Medical Center, a tertiary care, Level I trauma center to an affiliated community hospital 1.3 miles away. In this episode, we hear about how this practice evolved at CMC and the role COVID played as well as the benefits it has yielded in terms of expedited patient care, resource capacity, and more. Key Points From This Episode: An intro to Dr. Baimas-George, her education, residency, and research contributions. How Dr. Baimas-George came up with her triage program and the role COVID played. Why Dr. Baimas-George's transfer program was a good use of resources. The short transfer times that have been achieved and how this was accomplished. Criteria used to triage patients from the ER in virtual consultations. Determining whether performing Surgery will be faster at CMC or Mercy. Whether there were issues of inappropriate transfer or under/over-triaging. Other key outcomes measured such as cost, operative minutes, and bed day savings. Opening up space for more complex surgeries at the main hospital by shuttling less acute cases to the community hospital. Other benefits such as solving care discontinuity, faster disposition, and more.

In this episode, Dr. Raul Coimbra shares with us his vision for the the Journal of Trauma & Acute Care Surgery.

Welcome to the Sterile Technique Podcast! It's the podcast about Surgical Technology. Whether you are a CST or CSFA, this podcast helps you earn CE credits and improve your surgery skills in the OR. This episode discusses the cover article of the July 2018 issue of The Surgical Technologist, which is the official journal of the Association of Surgical Technologists (AST). The article is titled, "Staged Laparotomy in Emergency General Surgery". "Scrub in" at steriletpodcast.com and on Twitter, @SterileTPodcast (twitter.com/SterileTPodcast). This podcast is a Dybas Media production. Sound effects adapted from GarageBand and sindhu.tms at https://freesound.org/people/sindhu.tms/sounds/169065/ and licensed courtesy of https://creativecommons.org/licenses/by-nc/3.0/.

During this episode of the Pursuit of Health Podcast we pick up on our topic of Infertility as a Health Concern with a remarkably accomplished guest physician, Dr. Chrissy Guidry. After years of medical and surgical training in Louisiana, Ohio and California, she is now the Medical Director of the Emergency General Surgery & Advanced Trauma Life Support Service at Tulane Medical Center and the Associate Program Director of General Surgery at Tulane University. As an Assistant Professor of Surgery at Tulane School of Medicine she serves as a mentor and advocate for many young student physicians. Amongst her many accomplishments and innumerable services on professional committees, she has recently added a focus on addressing Female Infertility Amongst Physicians. She explains that she has been carrying out this effort in collaboration with the American Medical Women's Association (AMWA) who has recently made a concerted effort to bring this issue out to the public and the medical profession. This began with an AMWA-sponsored Physician Fertility Summit at which Dr. Guidry was amongst the many guest physician leaders and speakers shedding light on this little discussed topic. During our visit with Dr. Guidry, she bravely shared with our audience her own personal issues regarding infertility so that others may know that they are not alone. She explains that Female Infertility amongst physicians is 3-4 times higher than the general population and that much research is needed to understand both the causes of this medical condition and how to best prevent and treat it. Dr. Guidry reveals many of the obstacles, biases and misconceptions regarding infertility and family planning amongst physicians. She stressed that this is an issue that can seriously affect women physicians and their families. She advocates for early awareness of this issue amongst those she mentors and her colleagues. Together, Dr. Fethke and Dr, Guidry agree that physicians wishing to have children are more well-rounded and healthy people when they are able to do so, thus improving their professional and personal lives. Through organizations like AMWA and RESOLVE, Dr Guidry is optimistic that the issue of Physician Infertility is now out in the open. She strongly believes that physicians have a unique platform to address this issue for themselves and the public at large in order to improve awareness and access to infertility-related medical care. She looks forward to a day when physicians can study and practice in environments that are supportive and proactive for all physicians who are in need of evaluating their fertility as a significant component of their physical and psychosocial health. Dr. Guidry poinantly finishes our fascinating and emotional discussion by emphasizing, “ It is time for this discussion to be out in the open so people know they are not alone.” Finally, Dr. Guidry wants everyone to be aware of the upcoming AMWA and RESOLVE sponsored three seminars occurring in February through April 2022 entitled Moving the Fertility Conversation Forward. We at the Pursuit of Health Podcast can be reached for audience feedback on this episode as well as past and future episodes. We can be reached at drfethkemd on Facebook and Instagram, as well as our website at drfethkemd.com. Refernces: 1. Marshall AL, Arora VM, Salles A. Acad Med, 2020;95(5):679. 2. Stentz NC et al. J Womens Health. 2016;25:1059.J Womens Health (Larchmt)2016 Oct;25(10):1059-1065. doi: 10.1089/jwh.2015.5638. 3. Chandra A et al. www.cdc.gov/nchs/ data/series/sr_23/sr23_025.pdf. 4. Kemkes-Grottenthaler A. J Biosoc Sci. 2003;35:213 5. https://www.nytimes.com/2021/09/13/health/women-doctors-infertility.html 6. JAMA Surg 2021 Oct 1;156(10):905-915. doi: 10.1001/jamasurg.2021.3301. 

Join Drs. Ashlie Nadler, Jordan Nantais and Graham Skelhorne-Gross as they tackle Cancer Emergencies.   Case 1 - Learning Points: These are complex patients and multidisciplinary care should be provided with input from oncology.  A step-up approach should be used, starting with medical management prior to considering surgery in appropriate patients. Highly selected patients may benefit from surgery, namely those with a high performance status, a prognosis of months if the bowel obstruction was resolved, minimal carcinomatosis, and a single transition point. Diversion, bypass, or resection are all options, but a patient's capacity to heal related to recent systemic therapy needs to be taken into account.  Consent for surgery should focus on goals of care, quality of life, and achievable outcomes, and highlight the inherent risk in patients with advanced disease and a limited lifespan.  Case 2 - Learning Points: Colorectal malignancy is an exceedingly common cause of general surgical emergency and requires a thoughtful, systematic approach The role of stenting as a bridge to surgery in obstructing distal colon malignancy is somewhat controversial but can help to avoid permanent stomas; however there is some potential risk of perforation and possibly disease recurrence Treatment decisions should take place in the context of an informed discussion with the patient and consideration of both quantity and quality of life whenever possible Consistent involvement of a multidisciplinary team, including radiology, enterostomal therapy, and surgical oncology can be extremely useful in guiding complex decisions References: Shariff F, Bogach J, Guidolin K, Nadler A. Malignant Bowel Obstruction Management Over Time: Are We Doing Anything New? A Current Narrative Review. Ann Surg Oncol. 2021 Oct 18. doi: 10.1245/s10434-021-10922-1. Epub ahead of print. Ripamonti C, Gerdes H and Easson A. Management of malignant bowel obstruction. Eur J Cancer 2008 May;44(8):1105-15 Chen, T, Huang, Y. & Wang, G. Outcome of colon cancer initially presenting as colon perforation and obstruction. World J Surg Onc 15, 164 (2017).  Olmsted C, Johnson A, Kaboli P, et al. Use of palliative care and hospice among surgical and medical specialties in the Veterans Health Administration. JAMA Surg. 2014;149(11):1169–75. Dunn GP, Martensen R, Weissman D.  Surgical palliative care: a resident's guide. Essex: American College of Surgeons; 2009. Biondo S, Martí-Ragué J, Kreisler E, et al. A prospective study of outcomes of emergency and elective surgeries for complicated colonic cancer. Am J Surg. 2005;189:377–83. National Comprehensive Cancer Network. https://www.nccn.org/. Accessed October 15, 2021. Shariat-Madar B, Jayakrishnan TT, Gamblin TC, Turaga KK. Surgical management of bowel obstruction in patients with peritoneal carcinomatosis. J Surg Oncol. 2014 Nov;110(6):666-9. doi: 10.1002/jso.23707.  Please visit behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

Your patient is pregnant in her third trimester and she has acute cholecystitis...a relatively common but unnerving scenario.  What do you do?!  Do you operate?  Do you observe?  What about the baby?  Tune in and get the information you need to best care for this patient.  Hosts: Drs. Graham Skelhorne-Gross, Ashlie Nadler and Jordan Nantais.  Papers reviewed:  1) Fong, Z. et. al. Cholecystectomy during the third trimester of pregnancy: proceed or delay? J Am Coll Surg. 2019. 228 (4): 494-502. 2) Hong. J. et. al. Considering delay of cholecystectomy in the third trimester of pregnancy. Surg Endosc. 2020. Online ahead of print. FELLOWSHIP APPLICATION: https://docs.google.com/forms/d/e/1FAIpQLSfxhjxgCE9Ek263XuGkpqqbaNiK9sVnu3M7_LFYUZxhr38SZw/viewform

Join Drs. Matt Martin, Carrie Valdez and Red Hoffman as they speak with EAST President Dr. A. Britton Christmas about the management of surgical patients during the COVID-19 pandemic.  They discuss the latest American College of Surgeons guidelines for Emergency General Surgery, safety in the operating room regarding airway management and laparoscopic procedures as well as thoughts on tracheostomies, chest tubes and ED thoracotomies.  Links below for more information!  -EM physician Dr. Yale Tung Chen chronicles his COVID diagnosis and provides daily ultrasound updates on his Twitter account @yaletung -Minimally invasive surgery and the novel coronavirus outbreak: lessons learned in China and Italy.  Epub ahead of print available. https://bit.ly/2UozPX4  -EAST COVID-19 Resources and Information. This is meant to be a clearinghouse of information and protocols from various societies and institutions throughout the world.  https://bit.ly/2QSV5Cj  -Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (published March 2020) is available https://bit.ly/3dB9H2Z  -Department of Defense COVID-19 Practice Management Guidelines -COVID-19 App - Developed by Dr. Kari Jerge - Download the App - http://covid19medapp.com/View webpage - http://apps.appshed.com/1517747/ -Visit the Vital Talk website to help guide you in difficult conversations with your patients regarding COVID-19 https://bit.ly/2JnnNqQ  -CAPC (Center to Advance Palliative Care) is offering a free COVID toolkit, including symptom management tips that will help you with your primary palliative care skills https://bit.ly/2Uqu9w4  -Dr. Nick Mark's OnePager guide to the care of critically ill patients with COVID. Join us early next week for Part 2 of the COVID series- Nick will be one of our guests! https://www.onepagericu.com/

Joseph Sakran was shot in the neck as a teenager. He went on to become a trauma surgeon. When the NRA tweeted doctors should "stay in their lane," Joseph and others were outraged. Joseph started #ThisIsOurLane, an umbrella for health care providers and all the other communities who've lived and borne witness to gun violence. Guests: Dr. Joseph Sakran, Director of Emergency General Surgery at Johns Hopkins Hospital; Dr. Damon Clark, Assistant Professor of Clinical Surgery and Associate Medical Director of the Surgical Intensive Care Unit at the University of Southern California; Dr. Cedric Dark, Assistant Professor of Emergency Medicine at the Baylor College of Medicine; Kereen Constant, second-year medical student at Howard University; Dr. Meghana Rao, OBGYN, Baltimore, Maryland; and Dr. William Jordan, Population Health Transformation Lead, Center for Health Equity at the New York City Department of Health and Mental Hygiene.

In her role with Trauma and Emergency General Surgery, Ashley Meagher, MD, MPH, has assembled a group of volunteers that meet every other month and make quilts. In 2019, more than 150 patients and families at IU Health Methodist Hospital who faced end of life circumstances, received one of their quilts.

On an otherwise typical Friday night in 1994, 17-year-old Joseph Sakran, a high school student in Northern Virginia, was shot through his throat by an errant bullet from a fight at a high school football game.  Trauma surgeons saved his life, launching him on a career as a trauma surgeon and as a leading voice against gun violence.  Dr. Joseph Sakran is the Director of Emergency General Surgery at Johns Hopkins Hospital with additional expertise in General Surgery, Minimally Invasive Surgery, and Robotic and Laparoscopic Surgery.  He also specializes in injury prevention, outcomes research, trauma system development, public policy and advancement of surgery in poor resource settings.  Sakran is one of the nation’s leading professional voices against gun violence, dealing with it as both a public-health and political issue.  He is founder of Docs Demand Action, a “movement of Americans demanding common sense solutions to end gun violence in our nation.”

A discussion about the JTS Emergency General Surgery CPG with CDR Jacob Glazer, MD, a Navy Trauma & Critical Care Surgeon and Maj Andrew Hall, MD from USAF CSTARS.     Not all casualties are trauma patients on the battlefield. Listen to this podcast about the considerations for emergency surgery in the deployed setting that may … Continue reading Emergency General Surgery in Deployed Settings →

Acute mesenteric ischemia of all types is still associated with high mortality rates, despite advances in diagnostic modalities and supportive care, largely due to delay to initiate the appropriate therapy. Dr. Michael Sise joins us to discuss this relatively uncommon but challenging problem confronting the acute care surgeon. This is a comprehensive review you don’t want to miss.

Dr. George Koenig presented at the ECHO Annual Conference in 2017 addressing trauma and the standards to what is done during the "critical times" after injury to a patient. Dr. Koenig will discuss current standards and trends that he has seen as a medical director in the prehospital environment. He is a graduate of The Philadelphia College of Osteopathic Medicine (PCOM) in 2003. He also holds a Masters degree in Biomedical Science from PCOM. He is an Assistant Professor of Surgery in the Division of Acute Care Surgery: Trauma, Surgical Critical Care and Emergency General Surgery of Sidney Kimmel Medical College at Thomas Jefferson Univeristy. He is the Associate Medical Director of JeffSTAT. Check out our website for more information about upcoming events and announcements! ECHO HeliOps  Email tony.falzone@echoheliops.org for flight ops comms submissions!  RW logo designed in conjunction with ECHO member Bud Lavin photo submission.  Music provided by BenSounds.com

Episode 20: Dr. Angela Ingraham In this episode, host Dr. Jonathan Kohler will be talking with Dr. Angela Ingraham, a trauma and acute care surgeon here at UW- Madison. You may recognize her voice from her role as an occasional guest host for the Surgery Sett, only this time the roles are reversed! Dr. Ingraham is currently conducting research on trauma and emergency general surgery in order to develop quality indicators for EGS patients. She’ll be discussing some of her discoveries pertaining to emergency general surgery transfers and will explain some of the potential options for improving these patient outcomes. We hope you enjoy! Recorded 12/7/16

Session 28 Dr. Nii Darko is a community-based Trauma Surgeon. He's also an Osteopathic physician. Listen to his journey and what you should be thinking about. Dr. Darko has also been on The Premed Years podcast back in Session 196 and he is the host of the podcast called Docs Outside the Box. [01:05] An Early Interest in Trauma Surgery Practicing for almost five years now, Dr. Darko knew he wanted to be in two points of his life. As a seventeen-year-old, Nii had the opportunity to shadow a trauma surgeon in Newark, New Jersey, with his first exposure to trauma case was a person who got shot where they evaluated the patient and seeing a whole chorus of nurses and different medical staff helping the person. The trauma surgeon he was shadowing was at one corner of the room conducting the stuff, which to him seemed like an orchestra or rather a concerted type of chaos. The patient was taken into the operating room and when the doctor came out, he talked with the family. The doctor comes out of this operating room as a big superhero and saves the day. From then, he got hooked. Fast-forward to residency around ten to twelve years later, Nii noticed that general surgeons were doing everything including trauma and found himself moving towards operating on the unknown which to him was the fun part about trauma. You don't know exactly what's injured so you have to use all of these different detective-type qualities to figure out exactly what's going on. So Nii felt trauma surgery was the best mix for him in terms of taking care of patients who need things like appendix or the gall bladder and at the same time use his superman qualities in high-adrenaline and highly stressful situations. [04:40] Traits that Lead to a Good Trauma Surgeon Nii cites patience as a very big trait considering that oftentimes, with trauma, you don't know what's going on  and a lot of things are going on at the same time. Another important quality is leadership. You need to understand that it's a very highly stressful situation. You have the ability to take a step back, be patient and at the same time, have the qualities where you direct people respectfully. Nii stresses the fact that no man is an island, particularly in medicine and although you'll be making decisions on your own, you are leading a team and if you can lead them effectively, it's always going to end up, for the most part, with good results for the patients. Nii initially wanted to be obstetrician being greatly inspired by Bill Cosby of the Cosby Show who played the part of an obstetrician who was a positive African-American doctor figure. In fact in medical school, Nii was the first year representative for the OB/GYN club and he quickly realized afterwards that it wasn't for him. Orthopedic surgery was also in the running for a very short period of time for him but everything fell by the wayside when he did a rural general surgery rotation in the middle of Kansas and then knew from then on that general surgery was for him. [06:58] A Typical Day and Types of Patients Nii gets into the hospital by seven in the morning and a sign out period occurs where they talk about all the patients on the list, anything major that occurred the night before and then they talk about the plan for the next 12-24 hours. From 8 am to 7 pm, Nii handles different duties whether it be patient evaluation at the trauma bay or someone on the general floor. By 7pm, they do the sign out process again and whoever is on at night handles any situation that needs to occur at night and then do it all over again. Nii typically treats patients from all walks of life, children and elderly patients as well patients in their late teens and 20's. As a trauma surgeon, majority of patients he sees are patients in their teens to mid-late 20's and 30's, which he describes as the "invincible years" where people think they're invincible so they do more of the reckless stuff. Additionally, he sees a huge boom of geriatric patients consisting of the baby boomer generation who as they get older are more prone to falls and different types of mechanisms, making them the second largest patient population he deals with. 70% of his job consists of true trauma cases such as car accident, gunshot wounds, stab wounds, and critical care while 30% goes to general surgery. Only about 10-15% of his patients that come through the trauma bay get taken to the operating room for various operations such as removing a spleen or fixing a liver laceration or a washout of an exposed bone. A very small percentage of patients get taken to the operating room which is a significant shift from trauma surgery that our generation knows from most TV shows in the 70's and 80's. Because of how advanced technology now is, those days are way behind us. Now, you can study someone and take a look in their, say abdomen or chest, and have more information before you take them to the operating room. [12:08] Calls, Work-Life Balance, and Burnout In terms of taking calls, Nii works in a two-week-on-two-week-off type model which is basically a shift work where he and another surgeon alternate call for two weeks and he gets another two weeks off. No administrative work, no hospital work, no patients. So Nii works hard in Central Pennsylvania for two weeks and then he's able to get home for a week to see family. This makes it attractive for people who really care about being able to travel or being able to do things with their families that they may not be able to do in a regular type of job. But that said, Nii describes his two weeks on as tough. You can do it but it's not for everybody. However, Nii finds those two weeks off as very valuable. When his patients come back during the two weeks he's off, they have this agreement among all surgeon where it's no longer his patient but their patient. Hence, other doctors take care of him or treat him during his time off. Nii sees this as the wave of the future. It may not be necessarily two week in a row and two weeks off but more and more specialties are taking on this type of work model with varying number of days on and off and where they're working as a team. Considering the amount of work or the amount of patients one person has to see and to be able to have the lifestyle with the new generations coming up, millennials and GenX, he sees lifestyle as coming into center stage and as a result, this type of schedule is becoming a lot more attractive. Nevertheless, Nii still feels he has enough time for family since he's working very hard for two weeks and prior to this year, he was in a situation where he spent 24 hours in the hospital and another 24 hours afterward is for backup in case he's needed to come in. he ends up convincing the OR to give you time to operate early in the day which doesn't happen much due to elective cases filling in. So you may be spending an additional five to six hours in the hospital. Again, Nii stresses how tough those two weeks are and oftentimes, you may still not be able to see loved ones during that time, but during the two weeks off, you may still catch up. But it's not for everyone. Nii has still missed a lot of important life events and he honestly says there are times he's questioning if this is all worth it but in order to be human, you have to have that type of thought process at one point. Nii is not complaining but this is real talk. This is bringing to light something people have not talked about before and it may have been manifested in bad behaviors in the operating room. So it's important to have this type of discussions now. [17:35] Residency, Fellowship, and Competitiveness Nii did five years of general surgery residency which includes training in a whole bunch of various areas of surgery such as general surgery, surgical oncology, ENT, neurosurgery, a little bit of orthopedic surgery, but less focused on general surgery. Afterwards, he was allowed to practice general surgery and decided to do a one-year fellowship where he did additional training at University of Florida's Ryder Trauma Center. He got as much experience in trauma as he could as well as critical care experience. After his training, he became board-eligible to practice trauma surgery and critical care surgery as well as general surgery. Nii describes trauma surgery as not a very competitive residency for a host of reasons. For one, a lot of people are little bit nervous about the hours you work with trauma. Second, it's very stressful. Third, a lot of programs offer trauma so it's not as competitive as in the realms of vascular surgery or any other type of subspecialty such as laparoscopic surgery or bariatric surgery. For the most part, people may think of trauma surgery as not being too competitive but it's very hard to get into the top trauma centers like the University of Miami, Grey Memorial Hospital, USC in California, or Shock Trauma in Maryland, these hospitals. [19:55] How to Be a Competitive Applicant From a medical student's perspective, Nii cites the the key things for becoming a very competitive applicant to general surgery. First, set the groundwork by being an excellently trained general surgeon. Show your interest in general surgery whether it be going to conferences or shadowing a general surgeon. You're going to be doing a general surgery rotation so you may want to do an additional rotation as a third or fourth year doing a sub-internship in general surgery or trauma surgery. Get excellent letter of recommendation and do well on your board exams. Once you become a general surgery resident, make sure to have an open mind. Make sure you're giving every rotation that you're doing enough attention and being as open as possible to basically learn as much possible. Be open to the idea that maybe you thought you wanted to do trauma surgery but you're actually really interested in surgical oncology or what have you. At this point, which usually happens during your second or third year, start getting yourself involved in research or doing some additional trauma surgery rotations if you like or get yourself involved in co-authoring a chapter in a textbook if you're at a large institution that does that. As for Nii, University of Miami has opportunities for not only medical students but also for general surgery residents to attach themselves to one or two general surgeons who are making probably a 25-30-chapter textbooks. There are plenty of opportunities to get yourself ready but focus on getting into a general surgery residency and as a resident, start putting your hands in different ways to show your commitment to trauma surgery. [22:40] Tips for Choosing Your Program Nii says he wouldn't have done anything differently with how he chose his program. The way he did it as a fourth year surgery resident at Grey Memorial Hospital where there was a lot of trauma done, there were multiple trauma surgeons who train at various places and they've come to work at that hospital. What he did was querying all of those surgeons, going to various people and asking them about their program and why they think it would be good for him to train there. Aside from getting advice from them, he went online and looked up more about those different programs and even calling up the program directors where some of them accommodated him. Nii wants people to understand that medicine is an extremely small world but as you start to get into more sub-specialties like trauma surgery, it's a very, very small world. For instance, their chairperson knew the trauma director at Miami and they ended up getting introduced in that way so he got to talk to him and told him about the program. So he applied and ended up working for him. Additionally, when you apply you get the opportunity to interview at these places if given the interview, which is an opportunity for you to showcase how well you speak and think or how you are in person, outside, separate from a piece of paper. Also take it as an opportunity to interview them. Ask them in how well they train their residents or fellows and in doing well on their board exams, how much experience do they get operating in x or y, how much time do they get off. [25:00] His Hustle to Allopathic Residency as a DO Nii is a DO but he went to an allopathic residency program for general surgery. Based on the NRMP Match Data for 2017 for Surgery programs, out of 1,276 positions filled, only 64 were filled by osteopathic students. When asked about how it was for an osteopath to get into an allopathic residency, Nii explains how much he hustled which means grabbing an opportunity and not waiting for someone to give you an opportunity. He knew he wanted to do general surgery and was open to doing a general surgery residency at an osteopathic program. He went through the rounds of interview at all these different DO programs and at the same time he decided to interview at all different places. He got a phone call from three or four general osteopathic surgery programs that they have matched outside of the match, which was part of their culture. They at times will just agree to take in a certain person before the match. So Nii had no other places available to him to get into a DO general surgery residency. But since he got to interview also at allopathic programs, he still had that chance within that allopathic realm. He ended up doing a last-minute sub-internship at Morehouse School of Medicine in the Medical Intensive Care Unit (MICU). When he got there, he made it very clear that he was doing the MICU rotation because he tried to get into the SICU (Surgical Intensive Care Unit) rotation but it wasn't available. He actually got lucky he had a very good pulmonology critical care physician and he honestly told him that he enjoyed intensive care unit but at the same time he was really interested in being a surgeon but he took the opportunity since it was the only thing available to him. Then every now and then he would request to round with the trauma surgeons and then he eventually maneuvered that into seeing what they do in the trauma. He basically got his foot on the door and hustle his way into making sure they know him. As a result, he got accepted into their program. It wasn't until his second year that he had the opportunity to talk to the chairperson who accepted him because they saw his ability considering they have never ever taken an osteopathic medical student before. By the time he graduated from the program, he was the best resident that has ever come through that program. Nii's advice is to make sure that if any osteopathic medical students are ever interested in their program, you have to take them more seriously. Think that we're all going through the same trials and tribulations and stress. Nii thought they may think that because he's a DO, he's different but he went above and beyond and he crushed it. Back then, they didn't treat him any differently or did anything to make him feel that way, but it was the thoughts he had at that time. His advice to medical osteopathic students out there is if you want to get it then go get it. And if you have to get into a general surgery in the allopathic world, then go and be as aggressive as possible and take the opportunities that may be presented to you. Kick the door open and don't wait for someone to give you an opportunity otherwise you're going to be on the outside looking in. [31:40] Subspecialties, Other Specialists, and Special Opportunities As a trauma surgeon, your subspecialty is called Trauma Critical Care. You can go and get some additional education like other specialties can like take additional courses in ultrasound. This is very useful if you're trying to figure out if someone is bleeding in their abdomen or has blood anywhere else. Using it is cheap, quick, and it doesn't require moving the patient to a CT scan where their pressure can drop or end up dying of a collapsed lung. You can get additional training in mostly anything. It won't get you additional certification but Nii explains it's always good to have that additional training in your back pocket because you never know when you're going to use it. Moreover, if you want to get any type of additional training that would get you certified in something else, you may have to do an additional fellowship aside from trauma surgery such as laparoscopic surgery or plastic surgery. In trauma, Nii always works with an orthopedic surgeon for broken bones, neurosurgeons for head and spinal cord injuries, plastic surgeons and oral and maxillofacial surgeons for broken bones in the face or missing teeth, broken nose and broken sockets. Other specialties they work a lot with include cardiothoracic surgeons. Other special opportunities outside of clinical medicine for trauma surgeons can be EMS. For example, if EMS is called to a scene and a patient is found down, if there's enough training, and EMT may bring that patient to the ER and allow the ER to work that patient up. But if the patient has a bunch of bruises on the head or anything on the rest of the body that may suggest they've fallen, if a trauma surgeon did the education and ER comes together, they may be able to educate EMS as to what to do first. You can also create your own type of experience. You can do a podcast like Nii where he interviews ordinary doctors do extraordinary things. And as with any other specialty, the world is your oyster. Nii further says that as a doctor, whatever you do, you just have so many opportunities to do anything you want. There are so many ways that you can branch off and go into. [36:38] What He Wished He Knew Going Into Trauma Surgery Nii trained in Atlanta, Georgia and from his experience, he found trauma surgery as a burden in their hospital since majority of trauma patients at their facility were indigent populations. Other services are expensive  so if a patient with polytrauma comes through and they don't have insurance, it could be a huge expense for the hospital since a lot of that care has to oftentimes be written off. This normally occurs in areas where you have patients who don't have a lot of insurance or indigent populations. When Nii ended up becoming a trauma surgeon and going into areas where people have car insurance or people have other health insurances to pay for this, he didn't know that trauma surgeon could be as lucrative for a hospital as well as for the providers. And at the hospital he's currently at, trauma surgery is not a burden and instead is the biggest money maker for the hospital just because there are so many tenets of care. He wished he had known this before because he used to often get physicians who tried to turn him away from trauma surgery whereas in his current situation, trauma surgery is not seen as a burden and the administration can't get enough of trauma surgeons and want more of them. [39:00] Most and Least Liked Things About Trauma Surgery The thing Nii likes the most about trauma surgery is being the jack of all trades. He enjoys stressful situations and being trained in all different areas knowing you've got to stay calm. You get to orchestrate a lot of people and run a team and you're seeing someone literally from the door as they come in and all the way to when they're discharged and you're in charge of all facets of the care. He finds this very fascinating reason that the went to trauma surgery in the first place. On the flip side, the thing he liked the least is also the stress that comes with it that there's a lot to handle. In other specialties, you get to triage it to another person but you don't have this option in trauma surgery. There is constant stress which can eventually wear you down considering that Nii is still in his late 30's and he already feels the stress of that so he knows he can't continue like this into his 50's since it's not sustainable. But Nii loves this too so it's like an addiction. [40:45] Major Changes in Trauma Surgery Nii explains that trauma in the 80's and 90's was known to be not as operative as other specialties. There were even times when a lot of trauma surgeons lost the operative skills they've acquired during residency so a lot of trauma surgeons were not very good at operating. But a new field has come up called Emergency General Surgery or Acute Care Surgery, which Nii describes as a different thought process. For instance, if a trauma surgeon has to be in-house, he handles all the general surgery emergencies that occur in a hospital. This helps the general surgeons who have very busy elective services in the morning so they won't have to come in during the middle of the night to take out an appendix when at 7am they had a whipple surgery, which is one of the most intricate surgeries you can do in the abdomen that takes roughly about five to seven hours. So the general surgeon is no longer tired because he doesn't have to come in the middle of the night while the trauma surgeon can still get his hands dirty. Technology-wise, it continues to push things further and further. The obvious things would be technology getting smaller and smaller that you can transport patients with, which Nii considers as a small thing compared to the combination of trauma surgery and general surgery. [44:00] Would He Be Doing It All Over Again? If he had to do it all over again, Nii actually doesn't know if he would do it all over again. His thought process has changed a lot from medical school and residency, from a gunner mentality to now more of enjoying what he does and at the same time, he is no longer defined by being a physician. There is more to Nii Darko than just being a doctor. And if he had thought process in medical school, he may not have decided to go into general surgery and he may have decided to do something else where he'd be really be able to take care of patients not only in the way he would want to take care of them but also at the same time have a lifestyle where he can get away and that when he's off, he is off. No work no matter where he goes. Sure he does work two weeks on and two weeks off, but this may not be the same in another facility. As opposed to Emergency Medicine, you work a certain amount of shifts a month and you're guaranteed some time off. So if he had to do it all over again, he may have chosen something different. [45:40] Final Words of Wisdom Nii's advice to premed and medical students and residents looking at trauma surgery is to relax and take a big deep breath. If you want to be a trauma surgeon, there are plenty of places and spots available for you to get into trauma surgery. From a premed standpoint, focus on getting into medical school and being the best student you can be. At the same time, take opportunities to shadow a general surgeon and contrast that with shadowing a trauma surgeon so you can see the differences in how they practice. From a medical student's perspective, this is the time for you to really do as well as you can with your boards and with your rotations. At the same time, start laying the foundation for your commitment to general surgery if this is where you're interested in. Finally, as a resident, keep an open mind and give all of your rotations an equal share of your attention. At the same time, if you know for a fact that it's what you really want to do, go and get it. Don't let anybody keep an opportunity from you and know that trauma surgery is extremely rewarding. Although very stressful,  Nii enjoys it everyday and at the same time you deal with people at their most vulnerable states and being able to take care of someone every step of the way, not many other specialties say they can do that so he is very grateful and humbled he has the opportunity to do this. Links: Docs Outside the Box Podcast The Premed Years Podcast Session 196 (interview with Dr. Nii Darko) NRMP Match Data for 2017 University of Florida's Ryder Trauma Center