I am an associate professor of Surgery at Vanderbilt University in Nashville, Tennessee. My specialty training is in burn surgery, trauma surgery, and critical care. I established this web site to serve as an educational tool for residents. I post articles, lectures, an links to this site that would be useful to anyone interested in topics of burns, trauma, critical care, or prehospital care.
I have several podcasts on issues of ICU medicine, pharmacology, and Trauma Care
The podcast ICU ROUNDS is dedicated to the teaching of critical care. This podcast is listened to by physicians, nurses, respiratory therapists, and prehospital providers. The topics are selected based on items that are discussed while on rounds in the Burn ICU at Vanderbilt University. I typically present topics that interest me. Why? In my opinion, to be an effective and passionate teacher I simply cannot be passionate nor interesting talking about things that I have little to no interest. If I find a particular topic boring, I'm likely to be a boring teacher.
6.27.10 How big is a palm??
The use of the patient’s palm has been a widely accepted and longstanding practice for the estimation of size estimation of smaller burns. There has not been uniform acceptance as what defines a palm and how large it is.(Rossiter, Chapman et al. 1996) The area of the palm alone (not including extended fingers) is 0.5% BSA in males and 0.4% in females. When one included the palm of the hand and the palmar aspect of all five extended digits, then the area increases to 0.8% TBSA for males and 0.7% TBSA for females.(Rossiter, Chapman et al. 1996). Aside from gender differences of palm size, the size of the palm also varies body weight of the patient. As the patient’s body mass index (BMI) increases, the percent body surface area of the palm decreases. In females with a BMI of >31 kg/m2, the palm size inclusive of extended digits is 0.64% TBSA. (Berry, Evison et al. 2001)
6.08.10 Working on the final of three ICU rounds podcasts on the treatment of severe acute necrotizing pancreatitis.
6.08.10 Presently I'm in the Republic of Georgia teaching prehospital trauma care about 20 miles south of the Russian boarder.
4.27.10 Two recent articles on the relationships between physicians conflict of interest with pharmaceutical companies.
3.16.10 I've always avoided the directly answering the question "what are the chances?'" I hate this question. Even if you give someone the most grim prognosis or say a chance on 1 in 100 or 1 in a million, the outcome is live or die. Not 80% die and 20% live. These statistics negate the role of personal preferences, quality of life, faith, or previously stated desires of the patient. To highlight this concept in a comical role, I often have students watch this video clip. The outcome in these scene is not as serious of life and death. However, you will see that even when quoted pretty serious odds to you and I, Jim Carrey's character is pretty optimistic. I use this comical scene to illustrate a serious point. (Click to go to YouTube Video)
3.13.10 I think is a good educational read on the important details of when, who, and how of escharotomy. (click to read)
3.5.10 Giving several pharmacology lectures at EMS Today in Baltimore. Come out and say hello.
3.1.10 The present podcast is on suppurative thrombophlebitis. We see this on the burn center a few times a year. Thirty years ago, this was the leading cause of septic death in burn patients. (click to go to podcast)
2.17.10 Ogilvie's Syndrome is often encountered in the ICU. I recently posted a new podcast on ICU Rounds on Ogilvie's Syndrome
2.17.10 Sometimes we find ourselves in a problem when we have patients getting medications and the QTc is prolonged on EKG. In the case of psychiatric medications this can create severe problems in the patients mood. This is a new statement from the ACC and the AHA. (Click here for article)
1.27.10 Over the past ten years there have been dramatic shifts in fluid resuscitation. Enclosed is a recent press release regarding fluid resuscitation from the US military. <click to read>
1.10.09 Remember that in smoke inhalation patients can have a honeymoon period following the exposure of the smoke. Therefore, a patient can be exposed to smoke 2 days ago and then present today with respiratory failure from complications of smoke inhalation injury.
1.9.10 It's COLD!!! It is unseasonable cold in Tennessee with a air temperatures around 20 degrees Fahrenheit and chill factors close to zero. With these cold temperatures we see an increase in the number of cases of frost bite. Frost bite has degrees of severity similar to a burn injury.
1.07.10 In today's edition of the NEJM is an article that involves the relationship of nasal carriage of Staph aureus and the incidence of surgical site infection. It would seem like a possible beneficial application would be to identify those patients who have Staph aureus and reduce the probability of a post operative wound infections by preoperative treatment of the nasal colonization. A reduction in colonization could reduce complications and profound reduction in health care expenditure. However, the same information could also be used to identify those patients who could be at increased risk for complications as well as expenditure.
The US government's office of CMS has stopped paying for many infectious complications. Hospitals are at increases financial risk when a patient has an infectious complications. Such complications can cost hospitals in excess of $25,000 per episode and make the episode of care a financial loss for the hospital. Therefore, using the information in this paper, hospitals can identify those patients that are a greater risk and deny care to those patients based on microbiological and subsequent financial risk. Of consideration, is the large number of health care workers who would have positive nasal cultures for Staph aureus. The possible result is that a health care provider could be denied access to an elective surgical procedure. Another dimension is what happens if a provider, eg. an orthopedic surgeon, is found to be positive for nasal colonization of MRSA. Should he be allowed to continue to practice surgery and risk that his patients migh have a higher risk of infectious complications. (click to read article)
10.16.09 One of the major problems that we have when treating patients with smoke inhalation is that there is a decreased ability in clearing secretions due to increased cellular debris as well as decreased clearance from an injury to the mucocilliary apparatus of the tracheobronchial tree. Below is a photograph from a porcine model of smoke inhalation. (From Enkhbaatar et al., 2007)
10.7.09 A good review today on OR fires.
5.28.09 Please review the VAP dashboards on the clinical workstations and make orders as changes. Please reorder the RASS targets often.
5.21.09 A review of the literature was recently published (click to read abstract) details when patients who are chronically on steroids should receive stress dose of steroids of perioperative procedures.
5.20.09 I'm glad to be back home in Nashville after doing some brief travel for work. Today we are doing an operative case where we going to use some of the patient's skin that is grown in a lab. Dr. Carr recently wrote some notes regarding some details about the perioperative care of CEA.
5.19.09 What is wrong with hospitals? A lot. Most medical providers feel that they practice medicine based on best evidence. What about hospital management and leadership? There is a mountain of scientific. More than often, the problem that seems obvious are not the core problem. Here is a really good article on hospital operations.
5.19.09 Cultured epidermal autografts (CEA) are an experimental (per the FDA) method of grafting large areas of burns when patients have limited donor sites. On Wednesday, we will be doing one of these cases. They are a major headache.
5.18.09 I'm participating in the American Heart Association and Internal Red Cross's Scientific Advisory Board for First Aid. Two fun packed days of arguing about the scientific merit of various first aid treatments.
5.15.09 I've added a new section to the web site to archive Dr. Carr's teaching notes. These are great written summaries of complex medical problems. Dr. Carr sends these out to our residents, and I have decided to archive there here on the web site.
5.14.09 Sorry about not updating the page for sometime. My editor software crashed and I did not have the time to repair it. Two new podcast have been posted this week. Caustic ingestion has been put on ICU Rounds and a discussion of Albumin, Hespan, and hypertonic saline has been placed on Pharmacology for the prehospital professional.
2.21.09 A new podcast on ICU rounds is regarding the problem of refeeding syndrome. The present topic on PHTLS podcast is on the issues of providing prehospital care to the pregnant trauma patient and on Pharmacology for the prehospital professional the most recent topic is a drug profile on the drug atropine.
5.1.09 The pharmacology book is finally published. It is presently marketed to the prehospital market. It is a book that is written in the problem oriented manner unlike typical pharmacology books. Most pharmacology books present the books in drug class. All diuretics in one chapter and then perhaps another chapter on analgesics. This book presents a problem, such as chest pain, and then presents the drugs that would be used to treat that particular problem.
2.11.09 There is a lecture of hypernatremia that has been added to ICU Rounds. Also coming on Sunday will be a lecture on the physiological causes of hypoxia.
2.8.09 Epinephrine is drug that is used commonly when thing are not going well. Often when one needs to use epinephrine there may not be a tremendous amount of time until action is required. This is a podcast from the pharmacology podcast of a drug profile of epinephrine. (Click here to listen)
2.7.09 We've had several problems with patient having low or elevated serum sodium. I've posted a new podcast on treatment of hyponatremia. (click here to listen)
2.5.09 The National Institute of Medicine (NIOM) has issued several reports that indicate that one of several items that jeopardize patient safety is the "hand-off" of patients. I learned yesterday, that we at Vanderbilt are changing the expression to "hand over" to indicate a more passive process. Well, what ever the wizards of smart determine to call it, we need to do a better job. Please read this article about issues of "hand overs" and problems that occur when it is done poorly.
Also, yesterday we discussed when is it appropriate to transfuse a patient blood. Please read this review article on the benefits or lack of benefits on transfusion of red blood cells.
2.4.09 There is a lot of good stuff going on in the ICU for which we have a good deal to discuss. Listen to this podcast on myoglobinuria and traumatic rhabdomyolysis.
1.28.09 Upon reflection of the recent crash landing in the Hudson River, I though it would be appropriate to discuss the clinical manifestations and treatment of environmental hypothermia. I have posted a new podcast on the topic in ICU Rounds.
1.15.09 Thank God everyone was safe. What a heroic job by this flight crew.
1.14.09 Attending the Armed Forces Institute of Regenerative Medicine Meeting (AFIRM). Very impressive science. I hope that we will be able to participate in development of some of this science as well as clinical trials.
1.5.09 The Holidays are over and we can all get back to normal. We have an entire new group of residents. Please read the protocols as soon as possible. You are immediately responsible for the contents of the protocols. At the very least, please know which ones we have so you can refer to them as needed. Also review the contents of the podcast page listed on the the right of this page. There is plenty of educational content for you to consume while you are on the service.
12.24.08 Merry Christmas. I am grateful for the evening off. The burn unit is busy and
12.8.08 On 11.2.08 I made a post about the use of therapeutic hypothermia following cardiac arrest. Few hospitals have developed protocols for the rapid implementation of such a protocol despite the evidence. Well it appears that hospitals may not have a protocol but NYC EMS will. (See recent article in the NY Times).
12.7.08 Does more sleep make better doctors? This is an editorial on the New York Times It by no means represents an opinion by me as either for or against resident work hours.
12.1.08 A new month means new residents. Review the web site. Get to know the various guidelines and protocols. Also review the podcasts and article reprints. Try to listen at least three our four podcasts each week. Listen to the most recent one as well as topics that are relevant to the patients which you are caring.
11.20.08 Many in health care have always had the impression that health care is recession proof. We have learned with the current economic crisis that there are no rules. Hospitals and health care are not immune in this health care crisis. As people loose their jobs, they are likely to experience more illness and less wellness. This population will have less health care coverage. The result will be a negative financial impact to both hospitals and providers. If you think that this economic melt-down will not affect the health care sector- get you head out of the sand. (click to view article on Hospitals and Recession Woes)
11.18.08 I've posted a new article that discusses where are we currently in the treatment of toxic epidermal necrolysis. (click here to see article)
11.13.08 Often on rounds I am talking about the when we put people on mechanical ventilation we are spinning the physiology 180 degrees with profound implications. Here is a neat article that articulates many of these points. Remember, we "suck" and ventilators "blow." (click here to see article.)
11.9.08 Since the Van Den Berghe paper in 2001, there is been a considerable interest in the control of blood glucose in the critically ill patient. Advocates of tight control of blood glucose have desired glucose in the range of 80 to 110, despite the risks of hypoglycemia. Those of us who were skeptical of such tight control, wanted more RCT data, or worried about hypoglycemia were quickly labeled as heretics. I am of the opinion the glucose should be controlled in the critically ill (BS<150), but I want more data prior to determining that all patients should be clamped between 80 to 110. Included is a recent article from JAMA that performs a meta-analysis on all the trials on tight glucose control. Yes, a meta-analysis. But look at the paper prior prior to making your judgements. The results of the meta-analysis are not subtle. (Click to view paper) (click to hear the podcast)
11.5.08 What is the real situation in American Health Care? This is an amazing lecture that Congressman Jim Cooper (D-TN) gave on health care recently at the Owen School of Management at Vanderbilt University. I am a republican, and I was blown away by the intellect and honesty of Congressman Cooper. The people of Nashville are truly fortunate to have him representing them. (Click here listen to lecture)
11.4.08 A few comments from rounds today. We talked about some of the "evils" or dangers or RBC transfusions. (click to view article). Also we I am including an article on prone ventilation. As I mentioned on rounds, the use of prone ventilation improves oxygenation but does NOT improve mortality. (click to view article) However, I would argue that if you cannot get oxygen saturation up, prone does allow you to fight another day.
11.2.08 Last evening we had a discussion in the ICU about the role of therapeutic hypothermia following cardiac arrest. See enclosed article.
10.31.08 Enclosed is a recent article on the critical care management of the major burn patient. This appears in the current edition of Current Anesthesia and Critical Care. I think this general over view papers are great for the resident rotating on the burn service for a month.
10.24.08 The New York Times prints an opinion piece by Newt Gingrich and John Kerry comparing evidence based medicine to major league baseball. I am a strong advocate of evidence based medicine, but let's be intellectually honest about it's application. Too often, clinicians embrace the evidence when it supports their bias and ignore elements of the same article or that evidence that does not support their position.
10.23.08 Due to the nature of burn injuries, we have a close working relationship with our palliative care team. This group of professionals provide compassionate and multifaceted care to our patients and their families. A recent report also details that palliative care teams also save money, which is important in today's health care environment.
10.22.08 For the residents on the service, there are some podcasts that you can review in regards to current issues on the service. Review podcasts on topics recently covered on rounds: steroids and post extubation stridor, or one of the several podcast on sepsis. Also read the article on the surviving sepsis guidelines.
10.21.08 Please read this article on the consequences of poor sign-out. This article discusses what elements one should cover to provide an adequate sign out.
10.20.08 A new podcast is placed on the ICU rounds podcast. The topic for this week is part 2 on the discussion on myocardial infarction.
10.19.08 The web site is getting relaunched to try to keep all the educational materials and the protocols in one place. Residents are encouraged to check the site daily to keep up to date with what is happening on the burn service.