Dr. Christian Jones Memorial Episode with Mock Oral Board Cases

wanna read a short paraphrase of his obituary. Dr. Jones grew up in Winterhaven, Florida. He attended Harvey Mud College for undergrad, and then he attended University of Florida for an advanced mathematics degree while at University of Florida. He met his wife Lindsey, who was described as the love of his life. He graduated with a master's in math in 2003. He then attended the Keck School of Medicine at USC. He then served as a surgeon for 17 years. During this time, he worked at Johns Hopkins Medical Institute. In his final role was at MedStar Health as Chief of Surgery. He later stopped working as a surgeon due to illness and became a full-time dad to his daughter's Molly 11 and Penny eight. He was a very proud of his daughters and loved, uh, getting to be with them full-time. So, Lisa, just, how did you meet Dr. Jones and, and what were some of your first impressions of him? Yes, so I actually met Dr. Jones before he had moved to Baltimore and became a surgeon, uh, at Johns Hopkins. I actually met him in person at

an academic surgical Congress meeting, and it would've been in February of 2015. I just met him in passing at that meeting as you do, and I remember. Being struck by his big smile and how kind he was, and even those, those conversations that you have with a new person at a meeting, I could tell that he was a very thoughtful and genuine person and really seemed to take an interest in me and getting to know me in that brief interaction. And of course I knew of him. I knew from his sort of early. Work as really an innovator and early adopter with respect to use of social media in professional spaces. He really, I think, was one of the surgeons that demonstrated for all of us how to professionally use social media, both for education, for networking, for career development. And I think he did that very successfully. So I knew of him and then had the chance to meet him. And then later that same year, in fall of 2015, he joined

staff at Johns Hopkins. And I remember that there were rumors that he was coming and people knew him. Med Twitter was the big thing at that point, at Jones Surgery. Everybody knew him. And I remember asking the chief of Trauma, Dr. Dave Efron, if the rumors were true, if Dr. Jones was really coming to Johns Hopkins. And he said, yeah, we recruited him. And I was like, wow. And I remember being really excited because I had that brief interaction and he was, I. A really wonderful educator and I, I couldn't wait for the opportunity to get to work with him. And, and sure enough, he join joined Hopkins in fall 2015. I was finishing up my lab time around then, and so had the opportunity to work with him as a chief resident and really had the wonderful experience of learning from, uh, his expertise. And I'm grateful that I had that opportunity. And many of my co-residents and other trainees that had the opportunity to work with him, I think share similar sentiments. We were

all positively impacted by his, by his presence. He was a wonderful person. Had you already decided that you're going into trauma at that point in time, or how did that work? He certainly didn't scare you away from it. No, I was, I knew I was gonna do trauma since I was a first year medical student, but that's a different story. So I was on board with, uh, with becoming a trauma and acute care surgeon, and he further reinforced my, my interest in that discipline and was very supportive, was very, I remember the first time I walked into his office to staff a consult and, and he says, okay, sit down. And he pulls up his computer and there's this huge Excel spreadsheet and he starts inputting the data as I'm talking to him. And I, it was just, it just struck me as, as different, but he had a very different style of everything. Maybe it was the mathematician in him, right. In putting all the data. And I, I suspect every patient contact he ever had was somewhere in that spreadsheet. But I, he was incredibly

kind, incredibly caring, and in everything he did, he was. A fierce advocate for patients. And I think that's the one thing I remember most vividly about him was that he would always do the right thing for patients and always had the courage to stand up and speak whatever needed to be said to ensure that the patients received what they needed. And he had a way of showing us that the words that we use make a difference. And people around us are always listening and always paying attention, and always learning. And we really do have a duty to model our behavior in a way that, uh, upholds our core values. And, and for me, that was him. He was always a fierce advocate for patients and for, for anyone. He was a kind person and would always do the right thing. And that's really what I remember most from him and what I would hope to emulate in my own practice. One

thing we were talking about as we were talking about this episode is, is how he referred to us. So how did he call you, Lisa? Or, or what did he say? No, I, every other faculty member would call us by our first names, but Dr. Jones would always call us Dr. Tic, Dr. Canary. It was always Dr. So, and not just in front of patients, which I think we often do that to ensure that patients know that they're being cared for by multiple doctors. But, but even just in, in informal discourse. So you walk into his office. Hey, Dr. Jones, I have a new consult for you. Okay. Dr. Kadak, please sit down. Tell me more about it. He was quirky. He was funny. He was humble. He was kind. I'm pretty sure that when I walked into his office, there was usually a mug sitting on his desk that said, world's Okayest Surgeon. I have that memory, and I think it just gives you a little bit of insight into him. He was. A wonderful trauma surgeon. Completely confident, completely prepared

to do the right thing at the same time, so humble and so funny, and just. Kind a good person who never demonstrated any kind of ego. He just was a humble guy. Yeah. Yeah. Even in the, I'm gonna play a, uh, mock oral he did with me after this and, and it, hearing what you say, sitting down in his office, you'll hear that in this episode. His, Hey there, Dr. K, tell, tell me here, sit down. How are this very different approach? And it, it, it was very kind of calming start to the interaction and, but yeah, somehow I knew about the okay surgeon thing. I don't know if he posted it on Twitter or something at one point, but. That's hilarious. I, he did have that mug and I, I have a, a recollection of it and just a couple other things I wanted to share. Having reached out to some of my co-residents and, and what they remembered about him, he had a way of making you be decisive if you came to him and said, Hey, so, and this patient has this problem, I was wondering maybe we should do this, maybe we should do

that. And he would just smile at you a big grin and say, I don't know. What do you think he would push you to actually make the decision and be decisive and be a surgeon, have that ability to make a decision, even if it's the wrong one, but be confident. And, and I think he, he pushed us to do that. And then he also had a way of. Allowing you autonomy in the operating room, almost to the point where it was a little bit uncomfortable. Mm-hmm. He safe way, but he really did want you to learn how to be comfortable being uncomfortable and learning that in a safe space with his oversight was really an incredible thing. Yeah. That's so much to take away. Is there, do you have any as, as you spend the next few years, when you think back to Dr. Jones and your training residents of the future, do you have any core couple things you might take away from him? Yeah, I, I think first and foremost,

kindness. Recognizing that it is not an easy thing that we do, and everybody is, is contributing what they're able to contribute. And I think he also had a way of tuning into when people were having a hard day or just struggling or maybe had been up all night, who knows? But he had a way of showing that kindness and that ability to reframe the situation. And I think we would all be better if we could bring more kindness in into our interactions on a daily basis with everybody that we encounter. And then specifically with trainees. Uh, I, I, I'm still going into my fifth year as faculty, so I'm still fairly junior in the process, I think. And learning how to provide residents with graduated autonomy and really allowing them the ability to. Have, have control of the operation and feel like they are directing what goes on, and yet also maintaining

the safety, uh, of the situation, maintaining the safety of the patient. I think learning how to do that is still something that I'm still trying to evolve in that domain, but I think Kristen Jones somehow had it from the very start. He was able to provide a setting where we truly could learn and master our skills and, and provide the best high quality patient care. I think he was a master educator. He truly was. He somehow. Was able to do that in a way that that few others certainly could. And he was quite junior. He was, I think about the fact that I was training under him and he was about where I was now. He, it was his first several years when I had the opportunity to work with him. So the fact that he had mastered that ability to yeah, provide autonomy to residents so early on, I think, still, still really impresses me. It, it's not easy to do and I, I think he did it well. And so I'll try to bring

that to my, to my own residence and to my own practice. I'm sure you're making him proud. Yeah. And, and that's what's so cool about the virtual community, the med Twitter, and I, I knew there was people like you out there just in my interactions with him digitally and, and one or two times at meetings, I just knew there were people that he was training that were. Really seeing an, an excellent educator and learning so much, and so very jealous. And I'm glad that you got that experience and you get to pass that on and see, I, all of my interactions were just, for the most part, virtual. But just in those interactions, you could really tell he cared. He cared about others. He cared about surgery, he cared about educating surgeons. And every conversation I left with him, I always left smiling. He just had that sort of charisma about him that really transmitted to other people. So a year ago, it was last January, uh, of 2024, I sent him an email outta the blue 'cause I hadn't seen him on midwinter in years and I forgot, hadn't heard from a long time. And he responded right

back and he goes, hi, Dr. Canary. Of course. It's very nice to hear from you. I hope your life and career are still going. Well. It, it was always nice to work with you and I hope you have wonderful colleagues who tell you that regularly. And then he went on to describe his medical situation in retirement from surgery due to disability after his extensive surgery to treat recurrent cancer and that there was positives in it in him beginning to spend so much time with his daughters. At that point in time, I didn't know that it was as severe as it was, but Dr. Jones was positive, engaging, and caring, and I, I hope that we can all take a minute and reflect on how we are impacting those around us. I hope that a small piece of Dr. Jones' legacy can live in all of us and just interacting with someone. I was talking with Lisa about this at the beginning. It's weird that his death has hit me so hard and, and, and the, not just me, but the other people behind life. Jason and John feel the same way of a guy that we interacted with and did some podcasts with. Lisa, thank you so much. I really was excited to hear from a trainee of his 'cause I

knew his impact was felt widely, and so thank you for taking the time tonight. Thank you for the opportunity to remember him and I hope the listeners will get to learn a little bit more from him in perpetuity from all of the efforts that he put forth with with the podcast. Thank you again. Following this, there will be a 2017 episode of Dr. Jones grilling Ludo and myself while preparing for the general surgery oral boards. These are types of things he'd love to help out with and I think his personality comes out in the podcast. As you listen to this, take a minute to remember the extraordinary person and surgeon, Dr. Christian Jones. Welcome back to another Behind the Knife. And we're lucky enough to have Dr. Christian Jones and acute care surgeon at Johns Hopkins Medical Center. And Dr. Jones has given us some scenarios before in both trauma and acute care surgery and we had lots of great feedback and so we really asked him and begged him to come back on again and he, once again is sacrificing his Sunday night to join us. Dr. Jones. We really

appreciate it and that we're looking forward to, to learning from you. Kevin, it's a pleasure as always. I am really looking forward to absolutely torturing you and Woo. Sounds good, sir. We are ready. We've been getting beat down for a couple hours now, so we're just open, uh, souls here, so Absolutely. Let's dive right in then. Uh, who's gonna go first? I, I will, Kevin. Alright, Dr. Neri, um, this is Christian Jones. Very nice to meet you. I'm sure you'll do well today. I've got just a couple of scenarios for you and I want you to treat these just as you would treat any patient that you're treating in the hospital. There's no tricks here. I'll tell you the information that you need to know and of course, if you have any questions, ask anytime. Okay, great. Thank you. We're gonna start with a patient that you're evaluating in the emergency department. Uh, she's a 70-year-old woman who comes from her nursing home with obs

observation. According to the nursing home staff, she's unfortunately demented and unable to provide you with much history. According to her caregivers. She has a history of some abdominal surgery, uh, and currently hasn't had a bowel movement in four days. They said she's becoming worse in terms of her dementia and they think that she's having abdominal pain. She has a distended abdomen and on arrival in the emergency department, as I said, is demented, but appears to be stable, hemodynamically being able to protect her airway and is pleasantly having a conversation with you. Great. So I immediately, uh, go evaluate her down in the emergency room. I would, uh, look at her vital signs and make sure she has IV access. And then I perform a, uh, physical exam focusing on her chest and abdomen.

Okay, you do a good physical exam. There's no abnormalities in her chest. Her breath sounds are good. There's no sign of pneumonia. There's no heart murmurs, and she's got no scars there. She does have a midline scar consistent with a wide laparotomy, but no other obvious scars on her abdomen. To give a hint as to what her prior surgery may have been, she has a massively distended abdomen. The nursing home staff says she is not obese at baseline, and this is far out of normal for her. It's Pontic and she does have some grimace when you push on it though. No clear peritoneal signs or obvious easily localization of her pain. Okay, at this time I would do a rectal exam also. You do a rectal exam, there's really no stool in the rectal vault, but she doesn't have any significant pain and doesn't have any masses or bleeding either.

Okay. I would send off the C-B-C-A-B-N-P and coag and that would perform a upright KUB. Alright, on, uh, on your KUB, you've sent off your labs and on your KUB uh, distended loops of small bowel with gas throughout them, uh, some air fluid levels though you're not, uh, clear on exactly what, on exactly where those are in the small bowel and no significant, uh, stool burden or gas throughout the colon. No. Distended, uh, colon. That's correct. Okay. And at this point I would place a NG tube in because she has a bowel obstruction of, of some nature that I'm not clear on yet. And do I get bilious content back? You do not a whole lot, but it's thin ous, more like gastric with a little bit of bal in it. Okay. And given that I didn't see any free air on that, is there creatinine Okay. To undergo a IV

contrasted tt? It is. And you go ahead and look over the rest of her labs, you find that she has a white count of 10,000, a slight anemia of with hemoglobin of 11 and no other lab abnormalities whatsoever. So you go ahead and get your CT with contrast. Do you want po contrast as well? I, I forget. Was she vomiting at all or she was, I'm sorry? She was not vomiting. No. Okay. I, I'll do, uh, oral contrast. Yes. With IV and PO contrast, you get a scan of her abdomen and pelvis. It again shows significantly dilated loops of small bowel, really from the stomach all the way down almost to the ileocecal valve. There appears to be a calcified mass just before the ileocecal valve, and that's consistent with a point of obstruction. There's no free air. Okay? There's no free fluid. There's mild stranding in that terminal ileum.

Okay? I would give her IV fluids and keep NG tube in and observe her overnight to see if this distension improves. Her distension does not improve, and despite her NG tube overnight, she does become nauseated and vomits, uh, twice. Uh, no aspiration, no sequelae of that. Yeah, okay. I would consider a colonoscopy, but I'm not sure. Uh. What exactly it would give me in this scenario, especially with an unrepped colon. But, and given that I have a focal point of obstruction that's seen, uh, near the ileocecal valve, I would consent her for an exploratory laparotomy with, uh, possible bowel resection. Okay, so you take her to the operating room. Tell me what you're gonna do. I, I would perform a, uh, a midline laparotomy, about five centimeter superior to umbilical to five centimeters below the umbilicus, not, and enter her abdomen. Place the book Walter,

and try and evaluate that I would eviscerate all of her bowel and specifically start running the valve from the ileo seql valve to identify where this point of obstruction is identified. Okay, so you take her to the operating room, you do your exploratory laparotomy. Amazingly, she doesn't have terrible adhesion. You're able to find down in a right lower quadrant at the ileocecal valve, a firm mass, uh, which feels intraluminal. As a matter of fact, you think it might even be mobile. Um, it, uh, feels round and hard, uh, and is very clearly your point of obstruction. Okay? Yes. Uh, so at this point I, I think she may have a gallstone ileus, given that it's mobile, I would, I would milk the stone back and to a point of bowel that's uninflamed. And I would perform an enterotomy and remove this stone and then close the enterotomy. And then I would fully search her the rest of her small bowel for any other evidence of

stones. And then, and if I found no further stones, I would not perform a fistula takedown in this patient, and I would close their abdomen. Okay, let's move on to another case. Uh, when you're in the recovery room with this patient, uh, she is doing reasonably well, but you're asked to see another patient that one of your partners operated on. This gentleman has remained intubated after having a very difficult AAA repair. He had an open procedure for an inflamed that is a, a mycotic aneurysm, and again, it, it was quite difficult. They don't have any ICU beds, which is why he's still in the pacu. He, like I said, is intubated and sedated, and the anesthesiologist has asked you to take a look at him because it's now been an hour and a half since surgery and he hasn't made any urine. Okay. What are his vital signs? His blood pressure is one

14. That's 1 1 4, uh, over 70. His heart rate is 90. His pulse ox is a hundred percent on 30% by ET t tube. He is breathing 18 times a minute, but that's controlled with his ventilator currently. Okay. I would make sure he has IV access. I would attempt a, a fluid bolus to see if this could improve his perfusion, and then I would send off A-C-D-C-A-B-M-P coag and a lactate. Okay. You send your labs off, they're stat, they should be back relatively quickly. What fluid and how much are you gonna give him? I, I'd give him a liter of normal saline. Okay. Anything else you wanna do before administering fluid to him? He's currently not hypotensive. That's right. That's correct. And I, I would flush is fully, flush is fully catheter to ensure it's not clogged. And obviously the patient isn't

anuric at baseline. I, I read over his history to make sure he's not in renal failure at baseline. Um, that's right, apart from his known long-term aneurysm, he had no significant medical problems because of his vascular disease. He is on a beta blocker, but not on any other meds at baseline that you flush with 50 ccs of, uh, water and 50 ccs comes back. You examine the patient and find that he has a fairly distended abdomen but is otherwise thin. It's, he's sedated, so he doesn't have any response to your exam. The wound itself is still dressed, uh, but doesn't appear to have any bleeding through the dressing. Uh, you already given pulses, I'm sorry. What are his distal pulses? He has, uh, palpable strong distal DP and PT pulses. And does he have any blood on rectal exam? You do a rectal exam and he does have stool in

the rectal vault. It's brown and there's no blood. No blood. Okay. I'm concerned that he could have a bilateral ureter injury. I would perform a, a fast exam to see if there's a fluid in the belly. Yes, there is some fluid in the belly, but you call your partner who operated on this gentleman and he says no. We used quite a lot of irrigation because of the mycotic aneurysm, and I fully expect there to be some residual fluid. On your examination by ultrasound, there is fluid in bilateral upper quadrants and in the pelvis, but you're unable to quantify how much. Okay. And the patient remains stable and just has a distended abdomen with fluid in it. Okay? He, his pressure seems to be getting just a little bit worse. He's down to 100 systolic. 100 systolic. And what did his labs come back? So he has a CBC of 7.8 that's down

from 11 preoperatively, but he didn't have any intraoperative hemoglobin. His white count is 11,000. His other chemistries are significant only for creatinine of 1.8, up from 0.8 at baseline and an of 30. I would do a duplex of his aorta to see if the renals were covered in this case if, if they're able to do that, and if they're not, I would do a CT scan stat to evaluate if the renal arteries were covered with the stent. Okay, so you actually are able to do a, an ultrasound showing good flow to the renal arteries, but unable to visualize the renal veins bilaterally. Uh, there is fluid overlying just about everywhere in the abdomen that you are able to see, and at this point he is still not making urine. Uh, his heart rate's still 90, uh, but his blood pressure is now down to 90

systolic as well. Okay. Um, I would get a bladder pressure on him to see if he has abdominal compartment syndrome at this point. His bladder pressure is measured at 22. Okay. And he's hypotensive and he has fluid in his abdomen and he's distended on his abdominal exam. At this point, I'm concerned that either has blood or urine in his abdomen and he potentially has abdominal compartment syndrome, so I would take him back to the operating room for to re-explore. So you call your partner and your partner says that he's happy to come in and help, uh, but it'll take him a couple hours to get there. Um, are you gonna wait for him? I, I would not. Okay. You take him back to the operating room. You open his wound and you find, uh, rapid evisceration of bowel consistent with, uh, it being under high pressure. You talked to the anesthesiologist who says that his blood pressure has

immediately improved and is now one 30 systolic. He's still not making urine, but it's only been a, uh, a moment. Um, you find that he's got a lot of clear fluid throughout the abdomen, but only moderate edema of his, of his small bowel throughout. Okay. And so it's not blood. He's not exsanguinating in any way? No. Okay. That's correct. He, it's blood tinged, but, but it's not blood. I would send it for a stat creatinine and then attempt to evaluate the ureter in the retro pum bilaterally. Okay, the creatinine on the urine, sorry, the creatinine on the fluid is one. The ureters you are unable to identify in any way bilaterally. You reflect up the colon on the right in order to try to get a better view of the retroperitoneum, but of course the retroperitoneum is just entirely sock down. Right. Okay, so at this point I have less of a

concern for ureter injury causing abdominal compartment syndrome, and he is not bleeding. Is he otherwise? Hemodynamically normal at this point. Heart rate 90, blood pressure one 30 over 80. His peak pressures have come down on his ventilator and he's otherwise hemodynamically stable. Okay. I would place, I, I'd perform, perform a thorough abdominal exam for a bowel injury for, um, any kind of bladder injury. And if I don't identify any other abnormalities associated with the surgery and running the bowel, I would place an app there and resuscitate him in the ICU. Okay, let's call it good. That's the end of your two cases. First of all, was it fast? Was it slow? What did you think? I think I was a little slow on the second one. I think the first one we moved, I, when you said old lady demented, I, I was thinking sigmoid ous, that's what my brain was thinking the whole time. And that's good. Even when he told me

calcified thing seen in the ilio, seql valve still didn't register with me. But I think that one moved at, at a good clip. I think I could have gone, uh, at a better pace on the second one. So I think you did fine. Uh, in terms of the pacing, these are remarkably fast scenarios. I think one of the things that we miss, whether we're talking mock orals or just preparing in general for the oral exam, is that I. These are seven to 10 minute cases, and the goal is to get through the important points in those seven to 10 minutes. That doesn't mean you've cured the patient. That doesn't mean you've done absolutely everything you can possibly do, and, and that doesn't mean that you have to go exactly where the examiner wants you to go. But if you do go too slowly, specifically, one of the old things that, that some test prep courses recommended was asking for information and waiting for it in a

very slow fashion in order to stall so that you don't say anything stupid and that won't work anymore. Instead, the examiners will know that you're stalling and will probably take it out on you a little bit, but will certainly take it out on you in your scoring. So the important part is to go through this as you did in a methodical, systematic fashion, but relatively quickly that. Timing that we just did on the two cases was really, I think, pretty representative. You'll have patients that you're able to do the initial portion very quickly and end up needing to spend more time in the operating room or on post-op care. So there will be patients who are completely undifferentiated early on, and you'll have to spend a great deal of time. Yet once you get to the operating room, it's, uh, remarkably easy and, and takes very little time. So I, I think as long as you keep that pacing and most importantly, keep up the methodic. Easy,

systematic evaluation of your patients, you're gonna do great. So let's talk the immediate cases themselves. Yeah, the first one, gallstone. Ileus. Again, a classic case that will come up from time to time on the board. It's as you noted, associated with a chole cyto enteric fistula. You didn't actually find the fistula in this case, and that's not necessary. You it, especially in the patient who's acutely ill. Your goal is to get them over the acute problem more than anything else. You search to the small bowel for other stones that may be there, which was perfect. I think the only thing you reasonably. Could have done differently is taken the patient to the operating room earlier. That is as soon as you ed absolutely ileus. Um, and in this particular case, it wouldn't have made a great deal of difference if you had gone, uh, immediately or waited a day as long as you didn't continue to try non-operative management. And you, you changed that very quickly. So good job on that one.

Uh, questions on the gallstone ileus. Uh, yeah. From, you know, I think the most of the reading is that in the acutely ill patient, it is the correct thing to, to leave the fistula in place, uh, to fight another day. Is that, is that what you'd recommend for that scenario? That's exactly what I would recommend for that scenario, especially in the older patient who, uh, is almost always the patient that has the gallstone ileus. But remember, they're not going to tolerate a massive, uh. Surgery in the acute setting any better than an elective surgery. And probably much worse, I would not attempt a fistula takedown in this patient in that acute setting. Realistically, you, if you had tried to do that, I would've made it too difficult for you to do in an attempt to keep you from trying to dissect all of that out and causing more damage. It's not unusual for this fistula to be associated with a shrunken shriveled

gallbladder and be entirely unable to be removed without a biliary reconstruction of some kind, whether it's a hepatic ostomy or something similar. And, uh, again, uh, if you're able to avoid it in, uh, this elderly, demented patient, all the better. Great. Okay. So your second case, uh, is again, one of those classic non-differentiated, uh, post-op cases. It really doesn't matter whether this is AAA or some other case. Uh, the seven cases that we have, patients who don't. P postoperatively is exactly as you went through abdominal compartment syndrome, hypovolemia, mechanical obstruction, u ureter injury. And then the two that we didn't specifically go after, though you could have found them. Cardiogenic shock of course, and renal artery stenosis. Anything else is drug induced. But again, not typically immediately post-op or simple

tubular necrosis from intraoperative blood loss. Again, uh, keep those in mind and those should be able to come in a systematic fashion for you. I guarantee you there will be people who are listening to this who get the question of acute post-op polyuria or anuria, and we think that we're so accustomed to dealing with this on a regular basis that oh yeah, sure, we check the Foley and we give the patient, uh, a bolus of fluid and that's it. But again, certainly on the boards in your critical care questions, you're going to have it be the very last thing you check as what needs to be examined, uh, or treated. Again. In this particular case, it was an abdominal compartment syndrome, but really that's only because it was the last thing that you got to. It's the very last thing you had done. After checking everything else was flush the Foley, then that would've been the problem the entire time. Good.

Okay. It is, and once again, it it's supposed to be. It's not designed to make you feel stupid. It's not designed to do anything other than to make sure that you are approaching these in a systematic way. You don't have to think of absolutely everything. It's okay to ask questions and even to ask for help, for instance, by calling your, uh, partner who operated on the patient and finding out if he had any difficulties. But most importantly, remember the goal of the boards is simply to show that you're safe and that you're not going to assume that something's not a problem when it is. And I think you did a great job on that. Your presentation style is fantastic. You responded quickly without stalling, but also without just jumping into things. Very good work, doctor. Thank you. A little slow to the physical, physical exam part, but you, you got me there, so thank you. Yeah. And again, uh, that probably brings up an

important point as well, which is you don't have to be perfect on these. Once again, remember, the goal of the certifying exam is to show that you're safe and that you're not doing things that you shouldn't be doing. They understand that you're gonna be nervous, that you're going to, uh, sometimes forget really obvious things. Uh, and as long as it's not egregious and, uh, doesn't happen over and over again on every scenario you're given, that's really okay. You may not get a perfect score, but you'll get a passing score. Uh, so don't worry about that too much. Great. Thank you. Absolutely. Dr. Doe, are you ready for your turn? Let's do it. Fantastic, Dr. Doe, I'm Christian Jones. Thank you for coming. Just as we talked about with your colleague who you may have listened in on, we will go over a couple of scenarios today. I'm gonna try to keep the timing within what you would see on the real oral boards, but most importantly, what

I'd like you to do is treat these patients exactly as you would in real life. Not trying to simply guess what the examiner is thinking. Uh, you don't wanna get in my head, believe me. So, yes, sir. We're gonna start with our first case. You are called to the trauma bay, uh, with, for a patient who is three minutes away, uh, and reportedly has a gunshot wound to the chest. This is, uh, a report that you're getting from EMS and they say that he appears to be hemodynamically stable. He has good breath sounds bilaterally, and they'll be at your center in two minutes now. Great. In this scenario, I would go down to the trauma bay. I would mobilize my team. I would assign roles, uh, have someone who is, uh, at the head of the bed to manage the airway, assign a nurse to rapidly put on monitors, try to attain vitals as soon as possible, maintain a clear line of communication. I

would have a low threshold for activating the massive transfusion protocol. And with all these items in place, I'd be prepared to receive the patient. So the patient arrives. He is about a 20-year-old man who is awake and alert. He is scared and diaphoretic. He is sitting up on his stretcher. He will not let the EMTs lay him down and you move him over to your stretcher and hold him down while you start your primary survey. So take me through that. Okay, so for my primary survey I'm going to start with the airway, breathing circulation, make sure he has adequate IV access to large four IVs in the peripheral, and then disability GCS and pupillary exam, and then get a full exposure to start with my primary survey. His airways intact to voice. His breath sounds are equal bilaterally, but may be diminished. He has

pulses that are strong at his carotid and his femorals and equal bilaterally. His GCS is 15 though he is, I'll say non-medically, he is panicky and his pupils are four millimeters equal and reactive. You get a large bore IV in each arm. You connect him to the monitor and you find that he has a heart rate of 130. He has a blood pressure of a hundred over 70. He has SATs of 92% on room air, and he's breathing 30 times per minute. Okay. This is a young man who has compensated thus far, but I am certainly concerned about the asymmetry on his test exam. On that exposure, were you able to see where his entry and exit wounds were? Sure. So he has one penetrating wound consistent with a bullet wound

in the right anterior axillary line. At about the fifth intercostal space. You roll him, you check his other crevices and folds, and you're unable to identify any other wounds. Okay. Uh, at this point I would, uh, do my adjuncts to the primary survey to include a chest x-ray, pelvis and a, a fast occurring simultaneously. Okay. You do all of those things. There's no sign of fluid around the heart. There's no sign of intraabdominal fluid, but he does have bilateral pneumothoraces and apparent foreign body consistent with a bullet in the left hemothorax. Okay. So this appears to be a trans mediastinal injury. I would start with bilateral large four chest tubes in the trauma bay. You put in bilateral chest tubes. Yeah. You put in bilateral chest tubes. You get a rush of air with each one and three to 400 ccs of

blood out of each one. Okay, and could I reassess the vitals as well? They're the same. They're exactly the same. Okay. Great. At this point, the patient is stable, though he does have a penetrating wound to the chest. I'm wondering if CT scan could be valuable or I think that I'm going to forego CT scan and take him to the operating room. Given that this is a Tustin injury, what are you gonna do in the operating room? Given the transmedia sentinal nature of this wound, I think that the best approach is going to be a clamshell thoracotomy. So in the supine position, I would do a left sided anterolateral thoracotomy, come across the midline with the lipkin knife, and then extend that to the right side. Okay, so you do a clam shell. You find that there's moderate lung injury on either side, but that you've essentially missed

any important mediastinal structures. Okay. At that point, I would repair any of the moderate lung injuries. Place any additional chest tubes that are needed, close the chest and then take him to the ICU. Okay. When you take him to the ICU, he does reasonably well, but is remarkably difficult to wean from the vent. He continues to have difficulty with increased pressures, uh, that has increased peak pressures on his ventilator, and most importantly, every time you increase those pressures so that he's adequately oxygenated, he has large air leaks on his chest tubes. At this point, I would try, what I'm concerned about is a, a missed tracheal bronchial injury. I would attempt to clamp the tube and see how he tolerates that. Okay. Let's move on.

Okay. Your next case is a young man, also about 20 years old within the emergency department. He's a college student and has had a weekend of binge drinking. He was found down by his roommate on this morning and had difficulty arousing him. He's waking up now but is complaining of excruciating abdominal pain. Okay. I would quickly assess this patient immediately trying to ascertain how ill, ill appearing he is. I would, uh, as I enter the room, uh, look at his vital signs on the monitor, assess his ABCs, make sure he has adequate IV access, and has Resus resuscitation ongoing. So he does have IV access. He is getting a banana bag, uh, currently, like, uh, some people call it an Osler bag. Uh. Usual post alcoholic thi and folate

supplementation and fluid. He is, uh, tachycardic to the one teens, has a blood pressure of one 30 over 80, is breathing 22 times per minute, but is saturating a hundred percent on room air. His airway is intact, his breath sounds are clear and equal bilaterally, and he has palpable distal pulses. Great. I, uh, start with the focus history. Um, apart from the binge drinking, um, any other prior episodes like this, any other associated symptoms you could tell me about? He's able to report to you that about once a month he has a heavy weekend of drinking. Um, that's just part of his social life in college. Uh, he frequently passes out and, uh, the same thing happened in this case. The only thing that was different this time was, uh, during one of his many episodes of vomiting, he did vomit up some blood along with, uh, the, uh, contents of his stomach.

Okay. Um, at this point, I, uh, do a focused exam, um, checking for any epigastric pain, uh, as well as a cardiopulmonary exam. Um, and then I order a, a chest x-ray, upright chest x-ray as this is happening. Uh, you do your exam. He has exquisite epigastric pain and left upper quadrant pain. Uh, it's not peritoneal. Um, he does not have peritonitis, I guess I should say. Uh, but on uh, palpation it is quite tender. He, his cardiopulmonary exam is entirely normal with the exception of his tachycardia. And, uh, your chest x-ray appears normal. Your upper right chest x-ray appears normal. Okay. Alright. So at this point I would, uh, send out some labs, C-B-C-B-M-P, lactate and coag, but I think my leading differential item as I wait for those, I'm concerned about in the setting of retching a, a boho syndrome and

esophageal perforation that could certainly be missed on the chest x-ray, I would start with a, um, a gastro RAF and swallow. Okay. You do a gastro graft and swallow under fluoroscopy? Is that what you're going for? Yes, sir. Okay. Gastro graft and swallow under fluoroscopy demonstrates no extravasation of contrast, but rapid transit into the stomach and then the small bowel. Okay. And then I would try thin barium. While he's in that suite, you have the same findings. Same findings, okay. And with that oral contrast, granted that his creatinine's, okay, I would then take him to the CT scanner for a, uh, essentially a, a CT with the PO contrast that he had already had, as well as IV contrast of the abdomen. So his creatinine was fine. As a matter of fact, the only, uh, abnormalities that you had on his CBC and CMP, um, were.

Elevated white count of 14,000, elevated hemoglobin of 16 and a lipase of 2000. You take him to CT and you find that he has what appears to be a fluid collection posterior to the stomach that is not containing any air. He also has significant stranding around the pancreas, but no evidence of small bowel, obstruction of leakage or of free air or fluid in the abdomen. Okay, so at this point, uh, my leading differe choice pancreatitis, acute pancreatitis, as far as the fluid collection goes, uh, are there any features that make it appear more like a chronic pseudocyst as opposed to a, like a contained perforation? What features would you be looking for? So in particular for the pseudocyst I'd looking, be looking for any sort of a

feature, like a walled off cystic structure or whether it appears that way or if it appears more, there's just a fluid that's not walled off in that space. It looks like simple fluid without any inflammatory changes or mature rind around it. Okay. At this point, I would, uh, admit the patient to the ICU, whether this is a, it's hard for me to say exactly for sure whether this is a pseudocyst versus a containing corporation, but whatever the feature is, it doesn't sound to be contained, but start with the trial of non-operative management, putting the patient on IV fluid resuscitation. How much fluid are you gonna give him? So I would place it fully and use. Urine output to help guide my resuscitation. But I would start off with a hundred ccs, an hour of

lactated ringers and go up to as high as 200 if needed. Okay. He continues to have worsening abdominal pain while you're resuscitating him, but his lactate does clear to normal and his white count unfortunately continues to rise. Okay. At this point, this patient has failed this trial of non-operative management. I would consent him for an exploratory laparotomy. Okay, let's stop there. Alright. Dr. Doe, so you had two cases, what were your thoughts? Uh, boy sir. It was challenging. Both of these cases. Made my heart race a little bit good. That's a good start. They should, these are tough cases and if you're not a little bit nervous, you're doing something wrong. As far as timing goes, did you feel rushed? Did you feel you went too slow, too fast? I feel like unlike Dr. Canary here, I took a little bit

longer to establish the diagnoses in each. So I felt like I could have been a little prompter with that, and that would've given, given me more time on the backend for the, um, operative management and the postoperative care. Yeah, and in fact, in these cases, um, I will say though that your operative management was not the focus. And even when you feel that way, it may not be true. That is it, it may not be what the examiner is looking for, and that's okay. So don't you know there's. The, these are the surgical boards, so everyone thinks, okay, a big part of my goal is to get to the operating room so I can describe the case and look for the things that I can look for. And that's not always what the examiner is, uh, wanting to find out. In both of these cases, my goal for you was to decide whether or not you felt like you had to go to the operating room

rather than Yes, sir, what you were gonna do once you get there. So that, that is a big part of it. And in, again, in both cases, don't feel like you're wasting your time doing your preoperative evaluation or, uh, wasting your time outside the operating room. I promise. Uh, again, there are going to be cases like these where that's not the focus, so you're not messing up the time even though you don't want to stall at all. I. For the most part, it's gonna be the examiner's role to keep you on time to fit into that 30 minute, 28 minute window for your cases. For instance, if I have a, an examinee who is really stalling, then that's a problem. But for the most part, if we're just taking a little longer than I think, then I'll give them a little bit of information and skip ahead. Okay. Now you've decided to go to the operating room and you've opened the patient up. You're looking down in the right lower quadrant. What are you looking for, things like that.

Um, let's talk about your specific cases. The transmedia, sinal gunshot wound is, uh, again, from, for those of us who, uh, enjoy treating trauma patients, uh, this is one of the classic challenges, uh, that we can appreciate. Um, and the case as always, is. Trying to decide whether the patient needs immediate operative management and if so, what that operative management, uh, is. So you decided once you identified that he had a trans mediastinal, gunshot wound, uh, you decided to go straight to the operating room and do the clamshell thoracotomy. Are there other things you could have done? Uh, I think so, sir. I was certainly afraid, um, of a scenario where he would crash in the, in radiology, but I think that he was probably stable enough that a CT scan could have helped with operative planning. Um, additionally in retrospect, I think that doing a

bronchoscopy and an EGD at the time of the initial operation would've been very helpful. Okay. I think that both of those are very reasonable. Let me be entirely clear. Yes, you could have gone to ct, yes, you could have crashed in ct. And very much like we were talking about on Kevin's cases, this could be one of those situations where if you don't go to ct, you're gonna miss something important. And if you do go to ct, you're gonna crash. And the examiner just wants to see how you're gonna handle either one of those. Um, in this particular case, again, your goal is to do exactly what you would do in real life. For my patients in real life, if they're stable, even semi stable, like this patient, uh, they're probably gonna get, uh, a scan, uh, for me to at least help delineate what's going on. That's not necessarily required by any means. So going straight to the operating room is fine, but if you do go

straight to the operating room, um, you probably would very reasonably find a, a less invasive approach to start. So you mentioned the bronchoscopy and esophagectomy. I, if you had done either of those, you probably would've found a hematoma in on your esophagectomy, which you'll recognize as concerning for a contained esophageal perforation. If you hadn't done either those, that's fine, but the, there's one other procedure, uh, assuming you're not going to open the chest, there's one other procedure that I'd recommend that you do in this case. Any ideas? So you assess the. Stairway, you assess the esophagus and then you have a penetrating injury that we know goes across the mediastinum. So even though we've done a fast, it's probably reasonable, again, especially on the relatively conservative oral boards, it's probably reasonable. These do a cardio window. Mm-hmm. Okay, good.

So our next case was our young man who had been drinking and once again, very similar to our other uh, cases. This is a little bit of what you make of it. This could have been a. Something as simple as gastritis, or it could have been the pancreatitis that he obviously ended up having, or as you very quickly noticed, the possibility of, of Borge syndrome, uh, an esophageal rupture or even a gastric rupture. The other thing that I'll mention that it, it can be in a patient who has this as a chronic issue, is a perforated ulcer. Unfortunately, not all that uncommon. Your workup was very good. It was systematic, it was methodical. You knew what you were looking for, and you knew what questions to ask. The uh, uh, fact that you went to the ABCs because you were seeing this patient in the emergency department was absolutely appropriate. And really the only, uh, concern that I have. Let me throw it

back at you, thinking about it a little bit more in retrospect. Is there anything you might have done differently? I think it was nice to know, um, uh, a little bit more about, um. What prior symptoms, uh, that he may have had, uh, prior to all of this. That, and I think that actually not sure That's okay. That's why we do this. The only thing that I would significantly change about your evaluation is your decision to go to the operating room. Pancreatitis is a horrible disease, and for better or worse, more of us are seeing these patients after long after, in fact, they've been diagnosed with pancreatitis and are now having complications of their pancreatitis. The patients are more commonly being seen in medical intensive care units treated by physicians who don't have a surgical background, which is fine, but it does mean that we lose a little bit of that, uh, appreciation for the early management of the pancreatitis

patient. Something we still really do need to know, and part of that early management is the recognition that these patients can get. Incredibly ill without having a surgical indication. In fact, I would say that the comment that you made about failing non-operative management, unfortunately this is probably the typical course for non-operative management for this patient. He'll have a massive inflammatory response even without a, an infection going on. In this particular case, the simple fluid collection that was posterior to his stomach was probably a chronic pseudocyst, but could very well have just been edema from his pancreatitis as well. The fact that there wasn't any air in it suggest that it's probably not a perforation and at least acutely. State to be managed. Um, I think, uh, your concern is a very reasonable one. Um, given that we don't have a definitive diagnosis for that fluid collection. Uh, but once again, some minimally

invasive studies like an EGD may be able to suggest to you that, uh, or at least convince you that there's not a perforation there. Um, the white count continuing to go up is very common in pancreatitis, again, just due to that significant inflammatory response. But the fact that his lactate cleared means that you're basically doing just about everything you can. Now, that may be the case, even if it's lact didn't clear, but realistically, the non-operative management of pancreatitis is one of those, unfortunately parts that we're losing, which can still be incredibly important for your boards. So, Dr. Doe and Dr. Kari for both of you, I would say, uh, the, the biggest. Issues with these cases aren't issues that you have, but issues that so many people have with oral boards, and that is the goal of getting to the operating room and manage things operatively. For better or worse, not all of the cases that you'll

get on your certifying exam are intended to be managed operatively, and even if they are managed operatively, that may not be the focus of the case. Remember that you'll have cases on your certifying exam that, uh, include the decision not to operate that include the full methodical preoperative evaluation, and then some others that even though they're operative cases, the examiners really just wanna know how you're going to handle complications or how you're going to discuss a bad outcome with families. If you find that you're not getting to the operating room, that doesn't mean that you've made a mistake or that you're stalling or that you're going too slowly, it may simply not be the focus of that question. And similarly, if you have a complication during a case, it may be that you were gonna have that complication whether you did exactly everything right or not. And that's the focus of the case, is how to manage that complication. For

both of you, honestly, your presentation was good. Uh, you knew what you were looking for and the. Eventual treatment of the patient ended up being reasonable. Obviously we can discuss the minutia as we have done on behind the knife before about the appropriate imaging for the penetrating trauma patient or the operative or non-operative management of pancreatitis, but that's not really what we're doing today. Your goal to present that what you're doing, uh, is safe and that you're going to be a reasonable surgeon, um, I think is very well met. So nice job to both of you. Thank you sir. One question I have for the pancreatitis one is the, is the sort of early indication for to do anything in the weeks following and be patient not getting better. You repeat CT scan, you see some air in the fluid collection, and then you maybe get a perk drain placed by ir.

Would that be the next common scenario we see? So again, we have made great strides in the operative management, and I probably should say the non-operative management of severe pancreatitis. One step to that is do as little early on as possible in terms of invasive interventions. If you can prevent any drainage or uh, aspiration or certainly surgery for 30 days from the onset of their symptoms, the patient will do significantly better if you can prevent doing any sort of operative management, uh, to 60 days. They do even better than that. My current practice, um, on the patient who is ill but not crashing. Is, uh, if they don't have a, uh, massive hemorrhage for some reason, then I will attempt doing

absolutely no invasive interventions for the first 30 days. So that means no drains, um, that means no, uh, video assisted debridement, uh, but rather the medical aggressive treatment of the patient with resuscitation. And then if necessary, if they do end up having an infection, antibiotics, they'll likely continue to smolder for quite a while. But the longer that you're able to defer an operative management, that better, that patient will do. Great. Great. And we could probably have a whole podcast on pancreatitis and maybe we should. Yes, sir. Thank you for highlighting. Absolutely. So great. I think that was a very, once again educational podcast and we, I really thank you again for taking the time out of your Sunday night. It's getting pretty late out there now, so I appreciate it. Kevin and Wu, thank you both very much. Until next time, dominate the

day.