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Academic surgery Leadership Surgeons are surgeons

Why academic surgery: thoughts for medical students

One of my key areas of interest, and an active area of research for me, is the barriers to careers in academic surgery.  I’m honestly pretty excited about some things I’m looking into and learning on that front, mostly because I want to keep my colleagues, my mentees, and for that matter myself from being part of the attrition statistics.

A few months ago I was asked to write a blog post for the Association for Academic Surgery with the intent of convincing medical students with career intentions in surgery that academics is a great way to go, and that many options for a career in academic surgery are out there.  Since I just returned this evening from the Society for Critical Care Medicine Congress, I’m using this as an opportunity to cross-post my own work.

Sure, you’re a medical student who is interested in a career in surgery.  You hear people talk about  “academic surgery,” but you’re not entirely certain what that means.  More importantly, why should you consider academic surgery as a career?

The historic academic surgeon shows little similarity to the modern academic surgeon.  The conventional definition was that an academic surgeon was to be a triple threat- clinician, educator, and researcher. Part of that definition as a researcher was to be a basic science researcher; clinical research and outcomes, education, global health- none of those things were on the radar screen of possibilities for credible research.  Fortunately, times have changed and the definition of scholarly activity has broadened tremendously.  A simple review of the program for the Academic Surgical Congress demonstrates this increased breadth, with tracks dedicated to basic/ translational research, clinical trials and outcomes research, global health, and education.  In addition, many now consider administration to be a fourth facet to the ideal academic surgeon.  Although that does increase the theoretical demands placed upon academic surgeons, there is also growing recognition that the idea of someone demonstrating excellence in all four domains is less likely; promotion and tenure criteria at many institutions are being adjusted commensurate with that injection of realism into the process, now asking for recognition in perhaps two of the four domains.  This new view of academic surgery opens up many options for academic surgeons, and even within the career of many of the leaders of the Association for Academic Surgery we’ve seen the creation of a bigger tent as young surgeons innovate in their scholarly activity.  My take-home message for a junior resident or medical student contemplating the concept of academic surgery is that it is a career increasingly defined by those who are in it, with expanding acceptance of alternative forms of scholarship.

On to that next question- why academic surgery?  Certainly there are a few prerequisites that you should meet before you commit to a career in academics.  When I review the characteristics of the most outstanding, committed academic surgeons I know, they share a few key qualities.

  • They are innovative.  Regardless of their field of scholarship, they are always pushing the boundaries and looking for new and better ways to do things.  If you are risk-averse, you are unlikely to be happy advancing scholarship in your field, and if you’re not going to advance scholarship in your field, a career in academics is likely a non-ideal fit for you.
  • They are passionate about their chosen career and all facets of it.  Yes, all surgeons are passionate about surgery.  But among the true greats in academic surgery, you find that they are passionate about surgery and scholarship.  You’ll also find that their enthusiasm is infectious!
  • They are committed to academic surgery and they are tenacious in their promotion of the field.  In order to succeed in academic surgery, you need to be both a mentor and a mentee.  The best academic surgeons have never shied from either end of that relationship, and have used both roles as opportunities for growth.
  • They are always teaching.  Think about that person who really influences you in medicine and surgery- they are the person who always has a few moments to teach about clinical care, the state of research, the state of education.  When you engage them on those topics, not only do you get the benefit of their wisdom, but you also get to watch their faces light up when the talk about those things that get them intellectually or technically excited.

While a career in academic surgery might be viable if you don’t meet these criteria, you’re certainly more likely to succeed if you have these qualities.  Don’t be frightened off by them, either- with a good mentor and genuine enthusiasm for what you pursue, they’re not that difficult to develop.

Should you become an academic surgeon?  My answer at this point in my career is a resounding yes!  The field has so much to offer, and the idea of being on the leading edge at all times is irresistible to me.

 

Categories
ICU

My primer on Critical Care

I’m in San Francisco for the next several days for the Society of Critical Care Medicine (SCCM) Clinical Congress.  I intend to go home with some great new clinical blog topics for you all, but as a segué to whatever I learn here I wanted to get some key references out there for those who are newer to the world of critical care.  Secondary gain:  It makes a great resource for my students and residents.

This list is by no means comprehensive, and studies placed here are here based upon my opinions.  I’ve essentially selected one seminal or one “hot off the presses” publication for several organ systems.

Neuro:  Delirium is obviously one of our nemeses in the ICU, and we want to minimize the risks for it in our patients who require sedation.  Although it’s now 8 years old, a game-changer for me was Pandharipande’s study showing that lorazepam is an independent risk factor for delirium in the ICU.  Our pharmacist had the graph from the study taped to her laptop for over a year, and any time we started discussing sedation strategies I would point at it.  Related: Last January, SCCM released new evidence-based guidelines for the management of pain, agitation, and delirium in the ICU.  The guidelines are very helpful, but they also show many areas in which we still have significant knowledge deficits.

Cardiovascular:  I remember when I started my residency that levophed was typically referred to as “Leave ’em Dead.”  In hindsight, I suspect that this was simply because we weren’t using it optimally, and therefore our patient outcomes were impaired.  In contrast, I now often find myself trying to convince referring MDs that use of dopamine is probably not a best choice, even in refractory hypotension, because of the increased number of adverse events associated with its use.

Pulmonary:  Yes, it’s now 14 years old, but ARDSnet remains our standard of care for our patients with ARDS.  We may not always agree on PEEP or mode of ventilation, but low-stretch remains the standard of care.

Endocrine:  During my residency, we all got VERY excited about tight glycemic control in the ICU based upon the van den Berghe study.  Subsequently, we’ve found that tight control increases the risk of hypoglycemia, which in turn increases the risk for neuroglycopenia (which is bad) and mortality (which is worse than bad).

Nutrition:  The Canadian Critical Care group continues to lead the way in development of evidence-based guidelines.  These were most recently updated in April, 2013 (link is to the summary).

Heme:  The TRICC trial.  I’m eagerly awaiting our findings from the analogous burn study that is still enrolling patients.

Infectious Disease:  How many days of treatment are required for a ventilator associated pneumonia?  Less may be more.  Also, no learner should get through an ICU rotation without knowing about the Surviving Sepsis guidelines and being able to implement them in care of a patient.

Notes:  

  • The New England Journal of Medicine initiated a truly terrific case-based series of reviews on critical care last year.  These are highly recommended for practitioners new and old.
  • SCCM has a series of clinical practice guidelines, of which I have only highlighted a couple.  They are an excellent resource.
  • Again, these references are a starting point for core readings in critical care.  If I have committed a glaring omission, please let me know so I can addend.
Categories
Surgeons are surgeons Working and Living

Burnout and surgeons: We don’t like admitting it, but it’s real

Today will be my first “theme-based” blog.  Last Thursday I wrote about the challenges of ICU care and family conflict, and the implications that has for staff burnout on the ICU team.  Today?  I’m tackling that issue of burnout in surgeons.  It’s real, it’s prevalent, and it’s something we simply have to do better in both confessing and addressing.  For my readers, I am focusing on general surgeons today, recognizing that burnout does impact other surgical specialties and other medical specialties.  In the last 5 years enough literature has been generated on general surgeons alone that I wanted to focus on “my people,” as it were.

What I know about burnout from my personal experiences:

It’s awful.  I felt isolated, and I was certain that none of my colleagues could have ever possibly felt this physically and emotionally dreadful.  For me, it meant that a job that is truly a source of joy became a source of misery- I did not want to go in for the routine work, much less get called back in for anything.  I questioned anything and everything in my decision-making.  I talked myself out of my usual sources of stability (dinner with friends, running, yoga, reading fiction) because I foolishly thought that the martyrdom that might come with that deprivation would make things better.  I whined.  I self-medicated with food.  I contemplated who could take care of my cats if I moved to Alaska to be a river guide.  I was chronically pissed off, often short-tempered, and couldn’t understand why my life was so awful and how people would consciously sign up for this sort of misery.  If I had to summarize it in three emotions, I would go with exhaustion, shame, and fear.

What I know about burnout from observing colleagues and reading the literature:

Risk factors for burnout include being younger (which I believe is more a function of early-career, rather than chronologic age), having children, working more hours, being on call more, and working in an “eat what you kill” system.  Burnout increases medical and surgical errors, likely because we don’t have the cognitive bandwidth to use our best judgment.  Work-home conflicts heighten risk for burnout, and because in our society the burden of balancing work and home still falls disproportionately on women, this risk impacts female surgeons more than their male colleagues.  Oh, and residents aren’t immune.  I’ll confess that the worst burnout of my career was the last 6 months of my general surgery training when two colleagues were out on maternity leave and another was out interviewing for fellowships.  That business about work hours and being on call (and needing time off) is real, folks.  Trust me.

What we should be doing better:

The first step to addressing a problem is acknowledging it, right?  So, yes, we need to be honest about the fact that we do get burned out, and we need to admit it when we’re heading to that place or have arrived there (easier said than done in an ego-driven, indestructible lot like my colleagues).  As practicing surgeons, to care for ourselves and our future colleagues we need to model adaptive coping strategies and maintain a culture wherein surgeon well-being is encouraged.  We need to be honest with ourselves about how we’re  really doing, and if colleagues tell us we’re not doing so well, we should listen.  We should participate in fitness activities, find meaning in our work, and maintain a sense of gratitude (and therefore, by proxy, maintain a positive outlook).  Yes, that means that sometimes we need to flip the switch on being a surgeon and just be a mortal for a bit.

What has saved me:

  • Walks with my dog.  She finds so much joy in each moment that if I’m paying attention I can’t help but go along with her happiness.
  • Being creative.  For me this means writing (reasonably well) and painting and drawing (pretty poorly).
  • Yoga.  Do you know how hard it is to just SIT STILL and be with your body for 75 or 90 minutes?  It’s really hard!  It’s also really good for me because I can’t focus on anything else during that time.
  • My friends and family, and many of my coworkers.  They call me on it when I’m out of line.  They bring me chocolate when it’s a bad day.  They give me hugs when I need them most. They remind me that I’m doing good things and making a difference when I forget that I am.  In short, they love me when I feel like I least deserve it.
  • Being grateful for three things every single day.  Some days those things are pretty silly sounding because I’m struggling to find anything at all.  But, as Brené Brown reminds us, gratitude is at the core of joy.

What have your burnout experiences been, and how have you dealt with them?  More importantly, what keeps you from getting there?  Please share with me so I can learn, share with the other readers so they can get ideas.

I’ll close with a thank you.  This blog has been in existence for just shy of a month.  I am over 1000 views- and with lots of positive feedback- from you, my readers.  Thanks for reading, thanks for thinking, and thanks for being part of my journey.  I am grateful for you.

 

Categories
ICU

Burnout and heartbreak in the ICU

Three recent end-of life cases have made the news and have been widely discussed.  As an ICU physician, these cases all resonate with me in one way or another.

Even though many others have written about it from a variety of perspectives, I want to address what’s going on with Jahi McMath from the standpoint of the medical professionals who are taking care of her.  As a quick refresher, she’s the 13-year-old girl in California who has been declared brain-dead and whose parents have come into conflict with the staff at Children’s Hospital of Oakland over removing her from the ventilator.  The ethics of the situation have been widely discussed, as have the challenges of helping families understand what brain death really means.  The dialogue I am not hearing anyone have, however, is the one about the impact of caring for a patient with no hope of recovery on medical staff.

Fact:  Conflict is inherent in life and work.  I’ve recently written about the relevance of managing conflict in the workplace.  We also know that conflict (both professional and clinical) is perceived by up to 70% of ICU workers.  These conflicts lead to job strain, and are heightened by more severe conflicts.

Fact:  Job strain is related to burnout.  Amongst Norwegian ICU nurses, burnout (as measured by emotional exhaustion on the Maslach Burnout Inventory) is correlated with job satisfaction, job strain, and vulnerability.

Fact:  Ethical decision-making may be a risk for burnout in ICU nurses.  A recent Portuguese study showed a positive correlation between burnout and ethical decision-making, particularly on issues of withdrawing care, withholding care, or proceeding to terminal sedation.  Not surprisingly, these situations heighten emotional exhaustion.

I’ve seen situations in my own ICU when we, as medical professionals, recognize that we have exhausted our options for cure while families still struggle with letting go.  I’ve felt the stress and frustration of trying to find another way to communicate, using slightly different words, that I have no way to cure their family member, and that any intervention I might offer is likely to be harmful.  I’ve also seen the impact that this has on our whole staff, who are some of the most compassionate people I know; for lack of a more scientific way to put it, it breaks their hearts when we end up in that place.  I’m grateful to work in a place where we can have candid discussions and support one another through these episodes.  I honestly believe, and research supports, that open lines of communication are a key cultural quality in our ICU that keeps us from burning out.

It’s my deepest hope that the ICU staff at Oakland Children’s are being deeply supported by their system and one another.  I simply cannot imagine being in their position right now, and even though I’m not one of them, as part of the ICU family I can assure you that their hearts are breaking.

Categories
Leadership Working and Living

Reflecting on the year’s end

reflections

It’s that time of year when resolutions are omnipresent.  We make lists of things we’re going to do or things that we’re going to stop doing.  We air our dirty laundry about our imperfections and we swear that we’re going to run every day or lose those 20 pounds or get rid of our consumer debt- all admirable things, but all also ambitious things that you really have to be in a certain mental and physical space to make happen; I’m particularly attuned to that after cleaning up my financial self and losing 30-ish pounds last year.

The net result of resolutions is that we feel bad about ourselves in order to make them, and we feel bad about ourselves when we fail to keep them.  Yes, I’m one of those people who considers resolutions a set-up for failure and as a way that we reinforce those qualities we like least in ourselves.

I’m not against personal growth, and I definitely support trying to be the best version of ourselves.  What I’ve found more vital for me has been to spend a few minutes at year’s end reflecting on what’s been amazing and wonderful, what could have been more amazing and wonderful, and how I want to move those concepts into my next year.  In short, it’s time to take stock of where I’ve been and where I want to be next.

So, looking at 2013, what was amazing and wonderful?

  • Watching a mentee- who I mentored through her entire residency- finish her fellowship and get her first “big girl” job as a faculty surgeon.  Helping her with that transition.  Sending her all of my shoes when I gave up heels.
  • Travel to new places:  Puerto Rico in January was blissful for many reasons.  Finland in August was a rich immersion in a completely different culture. I now want a sauna house and a lake out back of my house!
  • Graduation of our first class of medical students who came through the “new” curriculum.  They seem to be thriving in spite of because of our innovations.
  • Walking in two Komen 3-Day events (Chicago and rainy, rainy DC) surrounded by dear friends.
  • Having a double-digit peer-reviewed publication year (in spite of my 50% education FTE!).
  • Making a little cross-country road trip with my Mom in September from Alabama to Utah, all in the name of rescuing a Siberian Husky.  She was worth every single mile.
  • Being part of the AAMC Women’s Mid-Career Professional Development Course.  I learned quite a bit about myself and about leadership.  Most importantly, I made some amazing new connections who I’m looking forward to a future with in academic medicine.

What was less amazing and wonderful this year?

  • Salt Lake’s wintertime air quality.  I’ve gone to referring to it as the “glop.”  It’s disgusting.
  • My role as a “track director” for our 4th year students.  My track is basically surgical potpourri and I don’t get a ton of help from the subspecialists.  I also struggle with how to prepare neurosurgeons and orthopedists for internship since I am neither of those things.
  • Losing my beloved Kita-dog to her old age, arthritis, and kidneys in August.  My heart broke wide open.
  • Having weeks when I was convinced that my primary purpose at work was to be a palliative care physician.  Don’t get me wrong- I really respect what our palliative care colleagues do, and as someone who works in the ICU I know it’s part of the job.  There are just those times that it becomes emotionally draining, and I had a couple of runs like that this year.
  • My constant efforts to put 10 pounds of sugar into a 5 pound sack.  Or to get 32 hours of work into a 24 hour day.  Regardless, my constant efforts to achieve that which isn’t completely reasonable realistic.  The biggest manifestation of this is my near-constant wish to be more generous with my time for my friends.

What’s next?

  • 2014 travel adventures:  Rafting the Middle Fork of the Salmon in June.  A Komen 3-Day in Twin Cities in August, including a birthday celebration for one of my beloved friends.  Maybe, possibly Australia in October?  We’ll see.
  • Refine the surgery clerkship that I completely burnt down in 2012.  It’s not perfect (yet) but it’s getting better all of the time.
  • Connection.  Details to be established, but for me I do know it’s both personal and professional.
  • Capitalize on my knowledge and experiences from the Mid-WIMS course so that it works for me and those around me.
  • Regularly take time off from work. Completely off, including research and administration.  Stop laughing and be supportive, will you?
  • Put together the best surgical potpourri “bootcamp” for April that I can with what I have. I’m letting go of perfect for this one, then reassessing what it really needs.

No resolutions.  Some dreams, some callings, but absolutely nothing to feel bad about here (well, other than maybe the bit about taking time off…I’ll get back to you on that in 52 weeks or so).

Happy New Year, and thanks for joining me on this journey.

 

 

 

Categories
Uncategorized

Beware of the treadmill!

Parents, beware that awesome new holiday gift that you got.

You know, the treadmill?  The thing you got so that you can run indoors when it’s bitterly cold or when the inversion is awful?

Probably not an ideal use of your new gift...
Probably not an ideal use of your new gift…

(Photo credit to normanack)

That treadmill, which we all want to believe is a great tool for improving health, is a hazard for little hands.  Some of the earlier research on this came from our group almost 10 years ago, when we demonstrated that the 48 injuries that we saw over a 6 year period that almost half of treadmill friction injuries in children required skin grafts.  The children involved in these accidents are typically 3-5 years old, and while the injuries are typically small and limited to the hand surgery is required for half of more.  Further, long-term issues with scarring may complicate the care of these children.

A 2012 publication shows that this is not a uniquely American issue, with similar findings reported in the UK.  A more recent examination of US data looking at all home exercise equipment re-confirmed the specific relevance of treadmills and the impact they have on children under age 4.  Perhaps most importantly, when I speak with parents of children who have sustained a treadmill injury, they simply had no idea that this is a relatively common occurrence.  They weren’t told about it when they were sold the treadmill, nor was information about the risk of treadmills to little hands anywhere in the box.

As a burn surgeon I struggle with these injuries because I believe they are almost entirely preventable with good education, but with bad care they can have devastating functional outcomes.  I’m not going to tell you to haul your treadmill out to the curb if you have a preschooler in your home; that would be a Draconian response to something that is largely manageable.  Remember that for the many treadmill injuries that we see in our clinic every year, there are many, many more treadmills that are safely used in homes.

How can you equip your home for safe treadmill use if you do have a preschooler?

  • If your treadmill has a key that is required for it to work, remove it when you’re not using the treadmill and put it somewhere that little hands can’t get to it.  Trust me, your 3-year-old is smart enough to use the key if they find it.
  • Make sure that your preschooler isn’t nearby when you’re using the treadmill.  Preschoolers are by definition a curious lot, and they don’t necessarily respond to being told not to touch something (sometimes it’s more of an incentive, rather than less, based upon my experience).  About 1/4 of documented injuries in two different studies occurred when a parent was on the treadmill, which means that it’s best to separate the treadmill and your preschooler.
  • The treadmill should be in a location where the operation of it can be supervised OR it should be in a location that can be preschooler-proofed against entry.
  • Be aware!  Reading this was already a first step for you.
  • And finally, we’re here if you need us.
Categories
Conflict Leadership

Conflict/ Opportunity

Conflict.

Did you squirm a bit when  you read that word?  Truth is that most of us probably do; when we think of conflict we think of  it in a destructive framework.  We think of how conflict at some point within a relationship or a group ultimately resulted in unworkable divisions.  It’s easy to forget those times that conflict, when sagely managed, resulted in an outcome better than the sum of its parts.  Yet, when used wisely, conflict can be constructive and provides a catalyst for change.  As hard as it may be to consider, conflict can serve as an asset to a group or organization.

Understanding the role and utility of conflict is a key leadership principle, and one that we spent several hours on last week at the AAMC Women’s Mid-Career Professional Development Course.  I’ll confess that I immediately had a bit of a visceral reaction to spending the better part of an afternoon discussing conflict.  Our homework for this session was to complete the Thomas-Killmann Conflict Mode Instrument (TKI) to measure behavior in conflict situations.  The TKI places people on two spectrums- one about assertiveness, and another about cooperativeness.  While I knew from the outset that I would not end up in the “competing” corner of the matrix (high assertiveness, low cooperativeness), I was dismayed to end up in the “avoiding” corner (low assertiveness, low cooperativeness).  That’s not how I see myself, and I hope that’s not how I am generally seen by those I work around the most often.

I responded to the TKI based upon one of the many settings I am expected to function in, and it’s one that I honestly consider dysfunctional.  It’s an environment in which I have, to use another phrase from the course, been “seen but not heard, or heard but dismissed” on a routine basis.  It’s tough to engage when you’re convinced that your thoughts will be immediately devalued, right?  Fortunately, I had a teammate who was listening generously when I described the environment and my choice to essentially not participate by being avoidant.  Jennifer wisely honed in on my description and simply asked, “Do you think that you behave the same in other settings where you have leadership roles?”  She then also suggested that I re-take the TKI based upon another of my settings.

Voilá.  I moved immediately from the unassertive/ uncooperative corner of the matrix to the corner that I view as “win-win” (collaborating- low on assertion, high on cooperation).  When I’m not in that mode, I tend to be a compromiser, with a rare tendency to pull out my bossy-pants and become competitive.  In truth, it’s only right that sometimes I do go into competitive mode as a surgeon-  when it’s a life-or-death matter it’s incumbent upon us to be assertive and steer the ship.

So, kudos to my wise teammate for pointing out to me the possibility that conflict style may be a combination of personal predisposition + situation.  I was also gratified to find that tidbit of wisdom on an Overview of the TKI.  I’m also trying to make people aware that you may deal with conflict differently based upon environment; I’m a clear example of trying to simply get by in one and trying to thrive in another.  I’m not sure it’s the “right” answer in the greater scheme of things, but it’s the one that keeps me sane.

What are your thoughts on conflict in the workplace?  How to you manage conflict with colleagues or team members?  Have you taken an instrument like the TKI, and if so, what did you learn from it?

Oh, and for those who celebrate…Frohe Weihnachten!

Some timely follow-up from the HBR blog

 

 

 

Categories
Uncategorized

“Flesh-eating bacteria!”

It’s honestly a bit impressive how much we hear about “flesh-eating bacteria” in the news.  Truth is, in the United States in a given year there are fewer than 3000 cases; our estimates aren’t very good because Necrotizing Soft Tissue Infections (NSTIs) are not a common disease.  NSTIs are just common enough that almost every physician will see a case at some point in their career, but they are not common enough for most physicians to develop true familiarity.  This lack of familiarity represents a true diagnostic challenge for many physicians when they evaluate a patient with cellulitis or a complex soft tissue problem that is not an NSTI- while they don’t want to inappropriately ask for help from the surgeon-specialist, they also don’t want to miss a disorder that is life-threatening in the face of inadequate management.  We do know that the reported incidence of NSTI has increased over the last 20 years.

So, what is an NSTI?

An NSTI is an aggressive soft-tissue infection that results in the skin and tissue below it dying.  This infection may be cause by a single type of bacteria or by multiple types of bacteria.  NSTIs are often life-threatening, and they require early and extensive removal of the infected tissue.  Patients with NSTIs also require post-operative care that can be quite complicated and usually have wounds from the tissue removal that require specialized care.

Who gets NSTIs?

Sometimes we can’t predict this; I have taken care of completely healthy women in their 30s who have an NSTI.  However, most patients who get an NSTI have some known health problem.  Our group’s study using NSQIP data showed that obesity, hypertension, and diabetes are all more common in patients who develop an NSTI.  Similar findings were generated by analyzing the NIS, which showed that obesity, diabetes, and liver disease were associated with NSTIs.

What does an NSTI look like?

Common signs and symptoms include redness, swelling, and tenderness of the infected area.  Unfortunately, these signs and symptoms are essentially identical to the clinical findings with cellulitis, which is not a surgical disease- it simply needs treatment with antibiotics for a full recovery.  A patient with an NSTI may present with an elevated white blood cell count and a decreased sodium level, but this is not always true.  The LRINEC score has been used to estimate the likelihood that a patient has an NSTI by giving point values for various laboratory values, with a score >6 having a 92% positive predictive value and a 96% negative predictive value.

What are the risk factors for mortality with NSTIs?

First, it’s important to understand that mortality from NSTI seems to be decreasing; two different recent analyses showed mortality rates of 9% and 12%.  This is likely attributable to better recognition of the disease, allowing for more aggressive early intervention, as well as improvement in critical care and wound care.

Patient age is clearly related to mortality, but severity of illness at presentation also plays a role.  Two different studies using NSQIP data have shown that emergent surgery is a risk factor for morality.  Last year, our group created a risk calculator for mortality consequent to an NSTI; the biggest flaw in our calculator is simply that it caps at an 85% probability of mortality.

Should I worry about my patient having an NSTI?

Usually, no.  These are rare infections.  I do say that with some hesitation because I know a disproportionate number of NSTI survivors…but that’s a product of what I do in my work.  Distinguishing the patient with an NSTI from a patient with “just” cellulitis is a genuine diagnostic challenge, particularly for those who don’t care for these patients often.  The important thing is that if the idea that something might be an NSTI enters your head, it’s worth it to talk to an expert.  If they do have an NSTI, the sooner they get to surgery, the better they are likely to do clinically.

Bonus information: Our SlideShare about the mortality calculator from the 2012 Western Surgical Association meeting.

Categories
Uncategorized

Does surgeon = jerk?

For those of you who follow me on Twitter, you’ve seen my feed the last few days filled with thoughts and comments from the AAMC Mid-Career Women’s Professional Development Course (#MidWIMS- storify from the meeting coming next week!).  The opening talk on Saturday was given by Julie Lien Wei, Professor of Otolaryngology and Division Chief at UCF.  One of her statements during her discussion of her career trajectory resonated deeply with me.

“I thought that becoming a surgeon was synonymous with being a (((jerk))).  One woman surgeon changed that.”

I’ll confess that I entered medical school with the image of surgeons as being less kind, less humanistic, and definitely less well-rounded than other physicians.  I was also very determined when I started medical school that I wouldn’t be a surgeon when I finished.  Fortunately during my 3rd year I came under the influence of a pediatric surgeon who epitomized a happy, enthusiastic, kind surgeon.  As a result of his influence and that of a couple others here I am, almost 20 years to the day from my acceptance letter to Texas A&M College of Medicine, happily ensconced in my career as a surgeon.  More importantly, I want to believe that I didn’t sell my soul to get here, and that I am every bit as kind, humanistic, and perhaps more well-rounded than my colleagues in other fields.

Even with the 20 years that have elapsed since my own decision-making, as surgeons we still have an image problem.  When I tweeted Dr. Wei’s statement, I had a student respond, “They are jerks.  The woman was an exception.” Ouch.

So this is all the further we’ve come?  As recently as 2010, one study showed that medical students enter with a negative perception of surgeons (good to know I wasn’t alone in that!). The perception that physician/ patient relationships are lower quality is a negative influence on selection of a career in surgery.  And we know that personality fit plays a role in specialty selection, meaning that if students consistently see behaviors that they perceive as incongruent with their values, they’ll vote with their feet.  However, the surgical clerkship appears to offer an opportunity for mitigation of these negative impressions.  Nevertheless, the perceptions appear to return to baseline within a year of the clerkship.

Clearly we aren’t yet where we should be.  We’re definitely not where I want us to be, and I’m basing that on information I see from my own students about how some of my colleagues and our residents behave at times.  Caveat:  I’m not saying I’m perfect every day because I’m not…but I try hard to be a good example, and if I sense I’m not being one I’ll own it.  I’m also generous with apologies if I’ve dropped the behavior ball.

Here’s my request for you, fair reader.

-If you are a medical student, what is your perception of surgeons?  How can we improve it?

-If you are not a surgeon but work with us, what do you see that we could change?

-If you are a surgeon, what do you see behaviorally in our specialty?  I know that bad behavior is significantly influenced by environmental tolerance (blog post for another day), but what else do you observe?

The bottom line, what I really want to resolve, is how do we fix our image so we’re not scaring off folks who would be incredibly talented?

 

 

Categories
Burns and frostbite

Baby, it’s cold outside!

It’s been really cold here in the Intermountain West for the last week or so.  In my line of work, that means that it’s frostbite season.  The phone calls for advice and clinic visits for care have gone into high gear after this past weekend. The other morning I had a colleague call me to help with the care of a family friend who was out skiing this weekend and came home with some really pale, cold toes.

Here are some simple frostbite education tips for anyone, as well as a link to a talk I’ve given on frostbite.

How do I prevent frostbite?

Frostbite is definitely in the category of things it’s better to prevent than to treat.  A few simple interventions can help you not end up with cold injury.  First, use warm clothing to maintain your core temperature (this is where the great coat comes in!), wear a hat to prevent thermal loss from your head, and make sure that you have good gloves and sturdy, dry footwear that will keep your feet protected.  Any clothing that you wear in cold conditions should not be constrictive.  And don’t forget that dressing in layers of technical fabrics provides you with additional insulation.  In addition to clothing interventions, make sure that you stay hydrated.   Monitoring hydration status can be a challenge in cold conditions, but it’s no less important than when you’re out in extreme heat.  “Cold checks” are another important technique for preventing frostbite, or for catching cold injury early when it can still be reversed.  If you have numbness or pain in your fingers, hand, toes, foot, or nose, it’s time to go in and warm up.  Finally, exposure in any temperature less than -15⁰C (that’s 5⁰F), even if the air is still, puts you at risk for frostbite.  If you can avoid being out in those temperatures, you should.  If you must be out, dress wisely for the conditions and try to get back indoors as quickly as you can.

How do I know if I have frostbite?  And what should I do about it?

It’s entirely possible to have a lesser cold injury like frostnip, which is easily treated with simple rewarming.  Frostnip usually happens on exposed areas like the nose, ears, and cheeks. Frost forms on the skin, but it quickly reverses with warming the skin and getting out of the cold.  Frostnip is fully reversible, but it serves as an important marker of conditions that are appropriate for development of frostbite.

Frostbite can present as either superficial or deep frostbite.  If you have superficial frostbite, the injured tissue remains a bit hard after it is rewarmed and often becomes swollen.  Superficial frostbite can even present with some small blisters with clear fluid, and these blisters are surrounded by redness and swelling.  The good news about superficial frostbite is that it results in very little tissue loss and it heals quickly with little need for medical intervention.

Deep frostbite is more concerning and has greater consequences.  Deep frostbite may present with purple, bruised-looking tissue, and the injury can extend down to bone quite easily in fingers and toes.  With deep frostbite we anticipate significant tissue loss, and this is the type of frostbite that often results in amputations for management of the injury.  If you see fingers or toes that have a deep purple color after being rewarmed, those need professional evaluation.

For initial management of frostbite, the Wilderness Medical Society released guidelines in 2011 that focus on being more than 2 hours away from definitive medical care.  A few key principles apply whether you are in the backcountry or in the lodge at Alta or shoveling snow in Salt Lake!

Initial Frostbite Management

  • Treat hypothermia (cold body temperature) first
  • Remove any jewelry on an affected extremity
  • Rapidly rewarm the affected extremity in a warm water bath that is 37-39⁰C for 30 minutes
  • Air dry the extremity- do not rub, and don’t pop any blisters (save them for the professionals)
  • Protect an injured area from refreezing and from additional trauma
  • Hydrate, hydrate, hydrate
  • Carefully pad the affected area to protect it and seek medical attention

For more information on frostbite, check my SlideShare.  Note:  If you may be offended by pictures of cold-injured fingers and toes, you may want to pass on the PowerPoint.

Edited to add:  An interview I did with Dr. Vivian Lee.  Happy listening!