You Either Pull Freight or You are Freight-Admonition #1 for Third Year Medical Students on a Surgery Service.

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Everything You Need to Know about Venting during Cardiac Surgery (And It's More than You Thought!).

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I Need You to be Me: Talking with Our Patients, Their Families, and Their Doctors.

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Zen and the Art of Thriving in the Clerkship Year of Medical School.

You, as third year medical students, are all among the best learners on the planet. You had to be to get into this, or any other, medical school. Your academic prowess has been put to good use both prior to and in the first couple of years of med school. However, you are getting ready to start into the rest of your careers, when many, if not most, of those finely tuned academic and personal skills will not be as applicable to learning and working as clinical trainees nor, eventually, medical practitioners, as those skills have been in most of your prior educational experiences. Candidly, when I was making this same transition myself, over four decades ago, it took me a while, probably quite a while, to really come to grips with this transition. Between those days and now, I have spent quite a lot of time immersed in medical education, at every level from younger medical students to chief residents training in thoracic and cardiovascular surgery. At each level of your education and training, you will have to sort out the best educational strategies for yourself.

Yoga Can Help You Practice and Teach Cardiothoracic Surgery.

Those who practice, and teach, thoracic and cardiovascular surgery and those who are training in this realm, as well as in many other disciplines, often endure debilitating physical stress and strain as a result of their practices. [Bishop, 2023] Despite the attention paid to issues such as proper adjustments for loupe magnification, optimal footwear, attention to 'micro-breaks', and paying attention to the ergonomics of performing long and intense operations, many surgeons still suffer discomfort and debility, and, even, disability. [Dalagher, 2019, Epstein, 2018, Alleblas, 2017, Giagio, 2019, Norasi, 2021] Dealing with those challenges should include what those practitioners can do outside of the operating room to increase their comfort and resilience, as well as what can be done in the operating room. One approach to dealing with these issues is to utilize the lessons and benefits of yoga. [Tribble, 2016].

You Will Be Held For Questioning: The Secrets of Multiple-Choice Test Makers & Test Takers.

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Give Me a Shot of Holy Water: Critical Elements in Myocardial Protection during Cardiac Surgery.

There is a surprising paucity of information on myocardial protection during cardiac surgery in the popular techniques books on cardiac surgery. For instance, Khonsari's otherwise superb book, Cardiac Surgery: Safeguards and Pitfalls in Operative Technique, has only three of its 300 pages that address myocardial protection, while Cooley's book, Techniques in Cardiac Surgery, has none at all. Similarly, the major textbooks of cardiothoracic surgery (Kirklin & Barrett-Boyes, Sabiston & Spencer, and Cohn & Edmunds) all tend to dwell on basic science and pharmacology, while barely addressing the actual techniques and strategies of myocardial protection during cardiac surgical operations. [Khonsari, Cooley, Kouchoukos, Selke, Cohn].

Time for a Cool Change: Getting off on the Right Foot in a New Job.

As a Thoracic Surgery resident approaching the end of your training, you may well have been in a single training program, perhaps mostly in a single hospital, for nearly a quarter of your life at the time of your graduation from residency. In a few months you will be going to work in other institutions in which you, obviously, have never worked. This transition will be challenging at best, and discombobulating at worst. You have been 'swimming in the water' of one place, likely taking a lot of that environment for granted, much as the young fish, described by David Foster Wallace in his book entitled This Is Water, did not comprehend the 'environment' in which they were living. [Wallace, 2009].

Sewing Proximals on the Ascending Aorta during CABG Operations.

To have coronary bypass surgery deliver on the claim made by Dr. Lytle in his Gibbon Lecture at the 2020 meeting of the American College of Surgeons, surgeons doing these operations must pay attention to every detail of the procedures.  While a lot of attention is, appropriately, focused on sewing the distal anastomoses in coronary artery bypass operations [Tribble, 2018], there is often comparatively less attention placed on creating the proximal anastomoses for coronary artery bypass grafts. [Favaloro, 1970]. A lack of attention to these anastomoses can lead to significant problems for patients undergoing coronary artery bypass surgery. This article will address the common issues to be considered in creating proximal vein graft anastomoses in a standard coronary artery bypass operation. Let's get started …..

Pull Up a Chair, Sit Down, and Listen.

When I was a medical student rotating on the various clinical services and thinking about career decisions, a common refrain from those offering advice on these decisions was that an early 'branch in the career decision tree' was deciding whether you liked caring for patients or liked doing procedures. I sensed that this advice was creating, or at least suggesting, a false or inaccurate choice. In fact, I even remember hearing that surgeons should not get too close to their patients in order to retain a sense of detachment. Somehow I just didn't see it that way.

All Bleeding Stops, Eventually (But: The Sooner The Better!).

It's your first day as the surgery resident working in the cardiac surgery intensive care unit (ICU) and you are accepting the hand-off of a cardiac surgery patient that your senior resident has brought up from the operating room for admission to the ICU. During the handoff, your resident colleague tells you that the patient is 'oozing a lot and that the operating team, after a diligent search for bleeding sites, does not believe that the oozing is 'surgical.' She announces that your job will, therefore, be to stop the ongoing oozing, while, of course, being alert to the possible development of tamponade physiology.

Helping Applicants Write Their Way into a Surgical Residency.

So, you've got students clamoring for help writing their personal statements for Surgery Residency applications? Writing a personal statement for an application to a residency program is often one of the most daunting aspects of the application process. In fact, it is probably the most daunting part of that process. However, there is a surprising paucity of information about how best to approach writing these residency application essays, in stark contrast to the plentiful advice available for other types of applications, such as those required for college or medical school admission.

The White Coat Ceremony: Welcome to the Medical Profession.

We have written about a number of the transitions, or 'lurches,' that most of us in medicine encounter as we move through the various stages of education and training in our profession. Some of our prior musings have addressed the transition into a Surgery Clerkship or a Surgery externship in the third or fourth years of medical school, respectively, as well as transitions into internship, the senior years of a Surgery residency, and a new job after completing Thoracic Surgery training. [Tribble: 2019, 2021, 2018, 2021, 2022].

We Were Residents Once And Young.

Each transition in the trajectory of a career comes with changes, some good, some challenging, and some changes are both. As you prepare to enter a Thoracic and Cardiovascular Surgery Residency (TCV Surgery), or the last few years of an Integrated Six Residency, you are well aware that you are likely embarking on one of the most demanding and challenging eras of your professional life. And, you are likely also aware that, as a TCV Surgery resident, you will have a limited amount of time to approximately double what you know about medicine and surgery. In fact, in these last few years of your formal training you will likely have fewer than 700 days to accumulate this necessary medical and surgical knowledge.

The Venerable Subclavian Line.

In this treatise, we will address one of the higher-risk procedures, subclavian vein cannulation, that a practitioner may undertake in the care of complex patients. All cardiothoracic surgeons and their trainees will need, on occasion, to put in central lines in a variety of circumstances, including in the operating room, in the intensive care unit, in emergency circumstances, and, occasionally, when other practitioners have been unsuccessful in their attempts to place a central line. We will describe, in detail, the anatomy of the subclavian vein, the preparation of the patient for subclavian vein cannulation, the infraclavicular approach to cannulation of the vein, and a few notes about the supraclavicular approach to the subclavian vein. It is self-evident that the priorities of central venous cannulation include safety of insertion, minimizing clot formation, and avoiding infection. We will dwell primarily on the principles of safe subclavian line insertion.

All the Light We May Fail to See: Learning from Talking to Strangers.

It's Spring in Virginia, and the senior medical students have gotten their Match results and are sending emails and texts thanking their mentors for the guidance and help provided in this final stage of their medical school trajectories. Their gratitude, of course, has reminded me of my own appreciation for those who advised, taught, and mentored me at similar points in my own trajectory. However, those recollections have also called to mind some other less traditional and, perhaps, underappreciated 'mentors' that I had the great fortune to encounter and to be influenced by. These thoughts have prompted me to reflect on my appreciation for these people who, especially in retrospect, helped me become a better doctor.

The Calm Before The Storm: The 4th Year of Medical School prior to a Surgery Residency.

Many medical students figure that their fourth year of medical school should be a time primarily focused on residency interviews and resting up for residency. While the interview part is necessary, the concept that one should be resting during that year is a myth. In fact, nothing could be further from the truth. Your top priority should be to prepare yourself to hit the ground running as a great surgical intern.

The Median Sternotomy: The Unkindest Cut of All? Pearls, Pitfalls, Aphorisms, & Myths.

While some have claimed that a median sternotomy is an 'unkind cut,' when this incision is performed, closed, and managed optimally, it can be one of the 'most kind cuts' used for major operations. The median sternotomy is the most commonly used incision for coronary artery bypass surgery, which is the most common operation performed in the United States at the current time. This approach is, of course, used for many other cardiac and thoracic operations, as well. It is, however, also one of the most misunderstood procedures in Surgery. Because it is an incision that even a novice surgical resident can perform, with proper supervision, the subtleties and nuances of not only opening but also of closing sternotomies are not often conveyed optimally to our trainees. In this treatise we will attempt to comprehensively address these subtleties, nuances, and misunderstandings, both for the benefit of our younger learners, but also, and more importantly, for the benefit of our patients.

The Mental Strategies of Surgeons: A Primer - Part II.

In this two part essay, we have addressed the mental skills and strategies of surgeons that students interested in a career in Surgery and residents training in this realm should have or acquire during their trajectories on their career paths. In Part I of this treatise, we covered the concepts of foundations, the hardy personality, preparation, and decision making. In Part II, we will address the concepts of vision, awareness and focus, reflection and analysis, leadership, and independence.

Electronic Glycemic Management System and Endocrinology Service Improve Value in Cardiac Surgery.

BACKGROUND: Postoperative glycemic control improves cardiac surgery outcomes but insulin protocols are limited by complexity and inflexibility. We sought to evaluate the effect of implementing an electronic glycemic management system (eGMS) in conjunction with a cardiac surgery endocrinology consult service on glycemic control and outcomes after cardiac surgery. METHODS: All patients with a calculated preoperative risk of mortality who underwent cardiac surgery before and after implementation of an eGMS and an endocrinology consult service were identified. Glycemic control and surgical outcomes were compared using univariate analysis, and multivariate regression was used to model the risk-adjusted effects of the interventions on glycemic control, surgical outcomes, and resource utilization. The health care-related value added by the interventions was calculated by dividing risk-adjusted outcomes by total hospital costs. RESULTS: A total of 2612 patients were identified, with 1263 patients in the preimplementation cohort and 1349 in the postimplementation cohort. Multivariate regression demonstrated fewer postoperative hyperglycemic events (odds ratio [OR] 0.8, 95% CI, 0.65-0.99) after protocol implementation without an increase in hypoglycemic events (OR 0.96, 95% CI, 0.71-1.3). Average day-weighted mean glucose decreased from 144 to 138 mg/dL (P < .001). The improved glycemic control correlated with a risk-adjusted decrease in composite morbidity or mortality (OR 0.61, 95% CI, 0.47-0.79). Although hospital costs increased after implementation, the protocol increased health care-related value by 38%. CONCLUSION: Implementation of a protocol consisting of an eGMS paired with a cardiac surgery-specific endocrinology consult service was associated with improved glycemic control and reduced morbidity. Despite higher costs health care-related value increased as a result of eGMS implementation.