By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Analyze the communities or environments in which patients live and work with regards to their impact on patient health
• Prepare for a procedure by preparation of physical environment (ex: equipment, personal protection, aseptic technique) and by cognitive preparation (ex: mentally rehearse anatomic landmarks, technical steps and potential complications and their management)
• During performance of a procedure, keep the patient informed and ensure patient comfort and safety always
• Display commitment to societal and community well being

Like all days working with the Portland Hotel Society (PHS), I started my day with focused medical learning objectives (I read over all of my extensive notes on how to prepare for and perform the perfect Pap) and came away feeling a mixture of overwhelm, curiosity, and passion to continue to provide care to marginalised people. While running a Pap clinic today (I say that because there was no attending physician present, just me), I learned of one particular woman's history involving significant physical abuse and associated emotional trauma that occurred within the environment surrounding the PHS clinic. I think PHS is amazing in how it brings access to primary care to the people of the Downtown Eastside (DTES), but I hadn't thought about how patients who no longer live and work in the DTES may re-live trauma every time they return to the DTES for ongoing primary care. Needless to say, I was very intentional about obtaining informed consent before the Pap test, with extra sensitivity to explaining why we perform Pap tests, the details of the procedure, and associated risks (physically, potentially a bit of vaginal spotting and pelvic cramping). I also gave her the opportunity to ask any questions, and let her know that if ever during the procedure she was feeling uncomfortable, we could always stop. During the procedure, I kept her informed by explaining what I was doing as I was doing it, and continued to check in to ensure she was comfortable (as comfortable as a Pap test can be, anyhow). The first principle in medicine is First Do No Harm, and in patients with a history of trauma, taking precautions to prevent re-traumatization is an important aspect of providing patient-centered care. After the Pap smear was all done, we discussed the possible transfer of her primary care to another low-barrier clinic situated outside of the DTES, but this was mostly kept as a conversation for another day given the multitude of other things that took precedence at this visit. 

Recently (aka from 8 am yesterday to almost 4 in the morning - we had a deadline to meet), my resident colleague and I were working on a literature review on the risk factors, protective factors, barriers and facilitators to treatment, and recommendations to promote better care of refugee women with peripartum depression. I was over it when I went to bed in the wee hours last night, but it was at the same time such a good learning experience, and today I was prompted to look to the literature to see what has been published regarding trauma that women have experienced living in the DTES. I found this informative article entitled, "'Like a lots happened with my whole childhood': violence, trauma, and addiction in pregnant and postpartum women from Vancouver’s Downtown Eastside" by Torchalla et al. (2015) as published in the open access Harm Reduction Journal. If you are at all interested in the peripartum experience of marginalised women, I recommend reading it. It also drives home pretty well perfectly the reality of this learning objective and why it matters for primary healthcare providers to understand and critically analyze the environments within which all patients work and live. The social determinants are more powerful than the prescriptions I pen.

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Assess and manage common post-operative complications (ex: atelectasis, infections, DVT, fluid and electrolyte imbalances)

As mentioned in a previous post on routine postoperative care, the following 7 Ps are postoperative complications I explicitly look for when routinely assessing all postoperative patients because they are common and seriously affect patient quality of life and length of hospitalization:

1. Pain/dyspnea
2. Prophylaxis (DVT)
3. Puke (nausea)
4. Poop (constipation)
5. Pass out (insomnia)
6. Physical exam (vital signs, ins&outs, labs)
7. Preexisting medical conditions

Here I will go over what to do to assess for the specific and common postoperative complications of atelectasis, infections, DVT, and fluid and electrolyte imbalances. I used UpToDate to inform my general approaches to each issue.

Atelectasis
I assess for atelectasis (i.e., collapsed lung) by asking the postoperative patient if they are experiencing dyspnea, and I also auscultate the lungs to listen for decreased breath sounds and review vital signs to look for evidence of respiratory compromise on examination. Although dyspnea, decreased breath sounds, and decreased oxygen saturation have  differential diagnoses and are not specific findings for atelectasis, atelectasis is a common reason for these symptoms/signs in the postoperative period. The impairment from atelectasis tends to peak approximately 2 days postoperatively, but it may be ongoing for up to a week postoperatively. Postoperative deep breathing exercises (ex: incentive spirometry) help to prevent this complication. 

The approach to treating this complication depends on whether the patient is producing respiratory secretions or not. In the former, a trial of CPAP can be attempted, with close monitoring to intervene with intubation if respiratory status is significantly compromised. On the other hand, if there are significant respiratory secretions, frequent suctioning and chest physiotherapy is first-line.

Infections
Infection may be signified by localised pain or other symptoms associated with a particular site of infection, or it may be signified by systemic features (ex: fever/chills, altered level of consciousness, leukocytosis). Note that postoperative fever in the immediate postoperative period is not uncommon and by itself is not highly specific for infection, but it is also to do ones due diligence to at least clinically assess and continue to monitor for infection until there are no longer any symptoms or signs  that could suggest an ongoing infection. Common postoperative infections include those of the surgical site, pneumonia, urinary tract infection, and intravascular catheter infection. 

If any source of infection is suspected, starting patients on broad spectrum antibiotics to cover suspected sources of infection is indicated. In the setting of postoperative infection, it is particularly important to start broad spectrum antimicrobials prior to obtaining the results of cultures & sensitivities, as hospital-acquired infections are more likely to be from antimicrobial-resistant pathogens, and that being said, it is best to refer your local institutions antibiogram to select antibiotics taking into account local resistance patterns. If a patient has an invasive line and is febrile, it is best to remove this possible source of contamination if not absolutely necessary.

DVT
A painful or swollen extremity in a postoperative patient raises the possibility of deep vein thrombosis (DVT). Risk of DVT is usually categorised as low, medium, or high, based on a clinician's gestalt of the individual's patient risk but often also by employing the Well's Criteria as a validated tool for estimating likelihood of DVT in a given patient. Postoperative patients with extremity pain or swelling are automatically high risk per the Well's Criteria, and as such they pretty well always warrant investigation by compression ultrasonography with Doppler. 

If a patient is indeed found to have a DVT, initiating therapeutic anticoagulation is standard of care unless the individual has a seriously high risk of hemorrhage that may outweigh anticoagulation therapy (in this setting, consider referral to a specialist for alternative therapies such as clot retrieval). While I won't get into the nuances of selecting a specific anticoagulant agent and determining for how long to prescribe it in this blog post, preferred postoperative choices include factor Xa and thrombin inhibitors, depending on patient factors. Anticoagulation therapy is needed for at least 3 months no matter the suspected precipitating factor(s) or lack thereof. Actual duration of anticoagulation past 3 months will be highly dependent on multiple patient factors that I also won't go into here, but the duration can for as brief as 3 months (if the DVT is deemed to be entirely circumstantial) to a prolonged 6 months, 12 months, or indefinitely depending on risk factors for recurrence.

Fluid and electrolyte imbalances
Depending on a patient's fluid and electrolyte status preoperatively, perioperatively, and in the immediate postoperative period, patients may require rehydration or maintenance fluid therapy. Evidence of dehydration clinically or based on laboratory investigations warrants replacement with small boluses of normal saline (or blood transfusion if indicated) until hypovolemia is corrected. If a patient has ongoing fluid losses without sufficient fluid intake, then a patient also needs to be maintained on maintenance fluid (ex: 20 mEq/L of KCl in D51/2NS, with a rate approximated by the 4:2:1 rule). Any patient receiving intravenous fluids requires monitoring of electrolytes (and some patients who are not receiving IV fluid but who have risk factors for electrolyte disturbance also require daily electrolyte monitoring while in hospital). Correcting for electrolyte abnormalities is important in the postoperative period to avoid complications secondary to electrolyte disturbances (ex: ileum, arrhythmia, seizure). There are a number of different ways to correct for electrolyte derangements depending on the particular electrolyte disturbance(s), and choice will again depend on individual patient factors.

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Perform minor surgical procedures and wound closures

While in clerkship, and so far in residency, I have had the opportunity to perform minor surgical procedures and wound closures on multiple occasions. My reference of choice is Procedures Consult.

Abscess Incision & Drainage
An abscess is a walled off collection of pus, relatively impenetrable by antibiotics floating in the bloodstream. For this reason, to treat it, it often needs to be incised and drained, to remove the bulk of the gunk and allow the body to heal the remainder. If the abscess is located in the dermis, the layer of the skin just deep to the superficial skin layer (aka epidermis), this is typically an in-office procedure that can be done in any general practitioner's office. In a purulent skin abscess, the causative agent is usually MRSA (methicillin-resistant Staphylococcus aureus), though in patients who are immunocompromised it is possible that there are other microbial culprits. Consider taking a culture of the abscess fluid in unusual circumstances.

Equipment:

• Local anesthetic (1% to 2% lidocaine)
• Syringe with 25- to 30-gauge needle, usually ½ to 1 inch, because only the skin over the abscess is anesthetized
• Chlorhexidine
• 4 × 4-inch gauze
• No. 11 blade
• Curved hemostats
• Sterile cotton-tipped swabs (optional, to explore the abscess cavity)
• Possibly iodoform packing gauze (¼- to ½-inch width and up to 24 inches long, depending on abscess size)
• Possibly culture materials
• Bandage scissors
• Dressing of choice

Procedure:

1. Obtain consent (ensure patient wants to have the procedure done after a discussion of the risks and benefits of the procedure, as well of the alternative options, including the option to do nothing). Risks of the procedure are as follows:
   1. Failure to resolve, causing cellulitis, osteomyelitis, or progression to septicemia
   2. Recurrence
   3. Formation of a fistula
   4. Scar or keloid
2. Position the patient so that the region with the abscess is well visualised and supported with the patient in a relaxed position
3. Don personal protection (gloves, gown, mask, eye protection)
4. Clean the skin overlying the abscess with chlorhexidine
5. Perform a superficial field block with a local anesthetic. The goal here is to freeze the overlying skin, not the deep tissue containing the abscess. Note that quite a bit of local may be needed as the acidic environment of an abscess makes the anesthetic less potent.
6. Once the overlying skin is frozen, make an incision, ideally with the lines of skin tension for better healing. If a culture of the fluid is to be taken, be sure to collect it from the contents of the abscess without contamination by contact with superficial drainage. Ideally, however, if a sample is intended to be sent for culture before it is incised, it is more ideal to collect a sample of the walled off fluid before incision with a large bore (18-gauge) needle.
7. Express as much pus as can be reasonably done.
8. Using the hemostats +/- sterile cotton-tippled applicators, explore the abscess pocket to be sure there are no leftover walled-off fluid collections. If present, gently break them open and drain the contained pus.
9. Pack the empty pus pocket with packing material (in a larger surgery as done in the OR, a drain may instead be inserted). After packing, leave a small end of gauze protruding from the wound, which will serve to drain the fluid from inside to out. Then the wound can be dressed with a sterile dressing and with a layer of ointment (or by using a nonstick dressing) so that the packing material doesn't stick to the dressing and get pulled out accidentally when changing the gauze, as may need be done frequently depending on how much purulence their is. Keeping the wound clean and dry is best.
10. Every few days, the patient can have their packing gauze reduced. Depending on the patient, they may be competent to do this themselves, or they may need to have followup for this with a healthcare professional. Every time, about 2 inches can be pulled out and cut off, leaving a tail of packing gauze protruding from the wound each time like the first time it was packed. The wound should be dressed just like it was after the incision and drainage.

Postprocedure advice:
After the procedure is done, the patient should be advised to watch for, and seek medical attention, if any of the following signs develop:

• Recollection of pus in the abscess
• Fever/chills
• Increasing pain, swelling, and redness
• Red streaking near the abscess

If patients are experiencing pain after the local anesthetic wears off, they can be advised to use acetaminophen +/- an NSAID as needed. They should also encouraged to bathe/shower as they wish, simply making sure to change the wound dressing afterward.

Wound debridement
To debride a wound means to remove dead tissue and foreign material from it. It is an important aspect of proper wound care to prevent infection, restore function, and improve cosmesis. All wounds must be examined for the need for debridement; depending on the history and physical exam, this need can be not at all or extremely compelling, with higher suspicion if wounds have a more traumatic or dirty mechanism of injury.

Equipment:

• Sterile gloves
• Sterile surgical towels and/or fenestrated drape
• Face mask
• Sterile gauze
• Scalpel with a No. 15 blade
• Tissue scissors
• Hemostats
• Small tissue forceps
• 19-gauge plastic catheter or needle and 35-mL syringe for irrigation
• Splash shield for irrigation syringe
• Sterile saline for wound irrigation
• For wounds in hair-bearing regions: petrolatum jelly or water-soluble ointment and/or small scissors to remove hair
• Good lighting source
• Tourniquet (may be needed if bleeding is not controlled)
• Non-adherent dressing material
• Absorbent dressing material
• Outer wrapping for dressing 
• Topical antibiotic preparation (optional)
• Supplies for local or regional anesthesia

Anatomy:
Skin is made up of 3 layers: the epidermis, the dermis, and the subcutaneous tissue. Below the subcutaneous tissue lie the fascia, bones, muscles, tendons, etc. This is a diagram from Procedures Consult showing the different layers of the skin, and a very well clean wound that has either already been debrided or that appears as though it doesn't need any debriding. 

Procedure:

1. Obtain patient consent (such that they choose to have the procedure done after you've assessed their understanding of the risks vs benefits of the procedure, and how it compares to the alternative options, including the option of doing nothing).
2. Observe universal precaution (gloves, gown, mask, eye protection) - just imagine how any patient you will be working on could have a serious blood-borne illness such as HIV
3. Position the patient so that they are comfortable and with the wound well-exposed and well-supported. You want to make sure you can sit (ideally) or stand comfortably and ergonomically to do your work. The laceration should be well lit and needed equipment should be within easy reach.
4. Before anaesthetising the wound, exam the distal or surrounding area of the body for neurovascular integrity.
5. Anesthetize the area
6. Cleanse the wound. This should be done as soon as possible after injury so as to remove bacterial and material contamination. Irrigate thoroughly. Although there is no evidence-based recommendation for how much to irrigate, a rule of thumb is 30-50 mL for every square cm of laceration. Regardless, continue to irrigate until all visible debris has been removed. Using warm irrigation solution is ideal for patient comfort. Making sure to clean and scrub the surrounding tissue, if needed, is also important, to prevent spread of the contamination into the wound.
7. After cleaning, disinfect the skin surrounding the wound (do not get disinfectant inside of the wound itself) and drape the wound to create a sterile field. Employ sterile technique now, with sterile gloves and sterile instruments. 
8. Explore the wound carefully to be sure there is no remaining debris. Examine for damage to deep tissue. Bleeding should be adequately controlled with local anesthetic containing epinephrine +/- the use of a tourniquet.
9. Identify and debride any devitalized or necrotic tissue with a scalpel or small iris scissors. Debridement technique may be modified depending on how the tissue is planned to be reapproximated, such as based on suture technique and natural lines of skin tension.
10. Reirrigate the wound to remove any remaining tissue debris.
11. If the wound is to be closed, it would then be done at this time, followed by proper wound aftercare. 

Insertion of sutures; simple, mattress, and subcuticular
Sutures are the most common way of closing wounds, and the closest I'll ever get to being a good housewife. Before beginning to suture, proper wound debridement needs to be done (as above). We suture skin to restore it's function and improve cosmesis (less scar tissue compared to healing by secondary intent). We do not suture skin closed if there is significant risk for contamination, because this increases the risk of infection, but usually this can be mitigated by good debridement.

Equipment:

• Skin cleansing agent, such as chlorhexidine 
  
• Sterile gauze
  
• Local anesthetic
  
• 5- or 10-mL syringe
  
• 25-gauge needle for anesthetic injection
  
• Saline solution
  
• 30- to 60-mL syringe with splash guard for irrigation
  
• Sterile bowl
  
• Sterile drape
  
• Needle holder
  
• Toothed forceps (Adson Brown)
  
• Suture scissors
  
• Suture material
  
  • Many choices here. Most commonly used is Vicryl for deep absorbable sutures and Prolene for superficial nonabsorbable sutures.

Anatomy of wound healing, completed quoted here from Procedures Consult because I don't like to make my life harder than it needs to be:

• Once a wound is closed, the initial phase of wound healing during days 0-5 is the inflammatory phase, during which coagulation begins and inflammatory cells, such as neutrophils and macrophages, are recruited.
  
• These inflammatory cells “clean” the wound with proteolytic enzymes, ingest microorganisms, and recruit fibroblasts.
  
• The epithelium is the only structure to regenerate during wound healing; this begins immediately after the wound is closed, during the epithelial phase.
  
• Within 48 hours, the epithelium regenerates and closes off the external surface of the wound to protect it from contamination. During this time, the wound is very fragile and has little tensile strength, relying mainly on external repair techniques to maintain closure.
  
• The fibroblast phase begins around 48 hours after injury.
  
• Fibroblasts that were recruited during the inflammatory phase synthesize and deposit collagen. The formation of collagen gives wounds their strength.
  
• Collagen production reaches its peak about 7 days later and has the most mass at 3 weeks after injury.
  
• The wound will continue to strengthen over the next year.
  

Procedure: 

1. Obtain consent (same idea as above). Risks to make sure patient is aware of:
   
   1. Infection
      
   2. Scarring
2. If loved ones want to be present, ensure they are seated for the procedure, and be sure there is a nurse who can attend to them if they feel funny.
3. Protect yourself before you wreck yourself (sterile gloves, gown, mask, eye protection)
4. Document neurovascular exam (as above)
5. Anesthetize the region to be sutured (to be discussed)
6. Position patient (as above)
7. Prepare wound including debridement, as indicated (as above)
8. Suture (see video below)
9. Postprocedure wound care (as above) [Consider need for tetanus prophylaxis depending on risk from mechanism of injury and patient's immunization status]
10. Document (at the endow any procedure, although not explicitly mentioned in the procedures above; it's just always the standard of care)

Laceration repair; suture and gluing
There are some situations in which a laceration can instead be repaired with a tissue adhesive (aka, skin superglue). When this is a feasible option and there are no contraindications, this can make closing a wound a super easy task, and it also typically means less scar formation. It is also pain-free and super cheap. Pretty much, when it can do the job, it is to everyone's advantage to use it over other methods of wound closure. 

So, when can we do this already? UpToDate recommends it for lacerations that are clean, that can be well-approximated, that are under low tension, and that are under 4-5 cm in length. It is particularly useful for fragile skin that cannot be sutured easily, common in the elderly patient. In wounds that are under too much tension such that the wound could dehisce using adhesive alone, deep subcutaneous sutures can be employed to relieve tension and allow the adhesive to close the superficial tissue (something to consider in cosmetically important areas).

The contraindications, per UpToDate, of using tissue adhesives for laceration repairs are: 

• "Wounds under tension, unless deep sutures are placed to permit wound approximation 
• Lacerations of the hands, feet, or joints, unless immobilized
• Complex stellate lesions, crush wounds, or other lacerations with poor wound approximation
• Oral mucosa or other mucosal surfaces (ex: vagina) or areas of high moisture such as the axillae and perineum
• Wounds in hairy areas unless the hair is trimmed
• Wounds requiring a high level of precision (ex: hairline or vermilion border)
• Bite wounds and other wounds at increased risk of infection (ex: puncture wounds, wounds with devitalized or contaminated tissue)
• Wounds in patients with allergy to adhesives (or formaldehyde), bleeding disorders, or comorbid conditions that delay or prevent proper healing

Procedure: The basics of the procedure are similar to the above procedures, in that the following elements must be included: consent, personal protection, patient positioning, wound irrigation +/- debridement, neurovascular examination, and documentation. The procedure itself is extremely simple, easily demonstrated with this UpToDate figure:

Aftercare is very simple. The sealed off laceration does not require a dressing, as it serves as its own water-resistant bandage. If glue gets on non-lacerated skin, it can be wiped off rapidly or if on the skin for greater than 10 seconds, it can be removed with the help of petroleum jelly. It usually peels off as the tissue heals over the next 5-10 days. Just like with placement of sutures, patients should return for medical care if any signs of infection develop, or if there is wound dehiscence. Otherwise, no further followup care is needed. Easy peasy lemon squeezy.

Skin biopsy; shave, punch, and excisional & Excision of dermal lesions, ex: papilloma, nevus, or cyst
Skin biopsy procedures can be useful for for diagnosing and treating various skin lesions. There are various techniques to select from, most commonly being shave, punch, or excisional approaches. The least traumatic method is the shave biopsy, as it only removes tissue protruding above the epidermis, removing epidermis and ideally limited dermis in the process. Naturally, then, this is insufficient for lesions that extend into the dermis, and it is absolutely contraindicated if the lesion being biopsied could possibly by melanoma (in which case the pathologist needs a deep dermal sample). If a shave biopsy won't "cut" it, then there is the option to do a punch biopsy, which is an easy way to gather a deep biopsy/tissue removal. These can remove between 2 and 5 mm in diameter of tissue, based on the size of the punch that is selected. These are great because they are just super easy to perform and if less than 4 mm, and sometimes if less than 5 mm, suturing the site closed is usually unnecessary. If neither of those two options suffices, using a good old-fashioned scalpel to perform an excisional biopsy is always a dependable technique.

Equipment (varies depending on the technique):

• Nonsterile gloves (sterile gloves and drapes are needed if sutures are to be placed) 
• Skin antiseptic (ex: chlorhexidine) or alcohol wipes (if not placing sutures)
• Local anesthetic (0.5 to 1 mL of 1% to 2% lidocaine with or without epinephrine), syringe with an 18-gauge needle for drawing medicine from the anesthetic vial, and a 27- or 30-gauge needle for injection.
• Specimen container, usually containing formalin (alternative transport medium required for culture)
• Surgical marking pen.
• Scalpel handle and blade OR 3- or 4-mm punch biopsy tool OR a single-edge flexible razor blade or scalpel blade (No. 10 or 15)
• Tissue forceps
• Sharp fine-tissue scissors
• Suture kit or Steri-Strips. Sutures or Steri-Strips are needed only if the biopsy site measures 4 mm or larger. Absorbable sutures (ex: Vicryl) may be needed for larger incisions.
• Antibiotic ointment.
• Adhesive bandage.
• Hemostatic agents (Monsel’s solution, aluminum chloride, or gel foam)

Procedure (in general, technique varies depending on specific method): Consent, positioning, clean or sterile technique, personal protection, planning biopsy (ex: for an excisional biopsy, plan to excise parallel to lines of minimal skin tension, outline area to be biopsied), anesthesia, remove tissue, control bleeding +/- suture, wound aftercare (as above).

*Note that the picture under the "Wound debridement" section above is what an excisional biopsy would look like after the tissue has been removed.

Cryotherapy of skin lesions
I debated even including this procedure in this section as a minor surgical procedure, but I opted to include it because it's useful to consider as an alternative strategy to surgical lesion removal, if appropriate for the type of lesion. It is much less invasive, almost always pain-free, and convenient to do in the clinic. It is commonly used instead of surgical biopsy for removal of the following sorts of lesions: warts, molluscum contagiosum, skin tags, papular nevi, and seborrheic keratoses. One of the downsides of this technique is that it can leave scars on people if they have darker skin pigment (but not in fair individuals), and you should think twice about doing it in patients who have chronic infection or who are otherwise immunocompromised because they may have more cryoglobulins floating around in their blood, and through some mechanism, this can lead to greater scar formation. You also want to make sure you're not freezing an area with a high degree of cutaneous nerves (may damage the nerves and lead to a permanent loss in sensation) or in which there is not the greatest source of blood supply to promote good healing (ex: lower legs in a patient with long-standing poorly controlled  diabetes mellitus).

Equipment = freezing agent

• Freezing agents can come in a smorgasbord of different vehicle options, and getting familiar with your applicator will be important to perform the procedure effectively. Most clinics use liquid nitrogen, but there are other agents that can be used such as nitrogen oxide and other refrigerants.

Procedure:

1. Obtain consent (the reason for doing it, what "it" entails, risks as outlined above, comparison to alternative options such as biopsy, with discussion of option to do nothing)
   1. ​Let the patient know that there will be burning sensation when the freezing agent is applied and then when it thaws seconds after. This will sort of feel like an ice cube stuck to the skin. This often reassures them that the pain is not all that intense. For people who are scared of this feeling, consider options for freezing (this can be as basic as simple cooling skin of the skin with ice, which is not really strong but may help to numb a bit, or applying a topical anesthetic, although this usually needs to be applied 60 min prior to have a decent numbing effect). Injecting local anesthesia would defeat the purpose, because this is more painful than cryotherapy itself. 
2. Prepare site prior to frozen, if indicated (with highly keratinised tissue as is common on the plantar surface of the foot, you may need to pare back some of the thick overlying skin to allow better access of the freezing to the target).
   1. The patient can help prepare a plantar wart by applying salicylic acid for 2 weeks prior to freezing in clinic. After cleansing the area, the patient can apply an over the counter solution of salicylic acid. Alternatively, the patient can use a salicylic acid pad, cut just a little larger than the wart. This is left on for 24 hours, until changing it out for a new one the next day. If the pad keeps coming off during the day, it can be used at night only and still have a good effect. After 2 weeks, when the patient present to  clinic for cryotherapy, a soft white layer of keratin can be peeled away to reveal the base or root of the plantar wart lesion. In lesions with significant keratin, a No. 10 or No. 15 scalpel blade can be used to shave off the keratin in thin layers until the first red punctate vasculature is seen (verruca). Stop debridement at this point to minimize bleeding. 
3. Position patient for their comfort but also for yours and to be able to see your work. 
4. Freeze (Good rule of thumb is to shoot to freeze for 5-10 seconds depending on degree of overlying keratinised tissue).For resistant lesion such as warts, do a freeze/thaw/freeze cycle. Freezing should extend about 2-3 mm outside the border of the lesion. 
5. Let the patient know that the development of a blister or scab is normal following the procedure. This should heal as any other scab does. If the lesion has not been completely removed, can repeat above every 1-3 weeks.

*Note that for common warts, the combination of patient-applied salicylic acid and physician-applied cryotherapy is standard practice. While this could also be done for genital warts, generally different strategies are employed. Good first-line options include

1. Patient self-treatment with imiquimod (5%) cream 3 times weekly until there is clearance, for up to 16 weeks of treatment
2. If patients cannot reach warts or there is no or minimal effect by 6 weeks, physician-applied trichloroacetic acid is second-line. Note that in a pregnant women who wants to treat genital warts, TCA is first line (although treatment of genital warts can usually wait until after delivery).
3. Laser and cryotherapy are next line options.
4. Consider biopsy to exclude precancerous or cancerous lesions if patient is immunocompromised or postmenopausal, when the lesions are visually atypical, or when warts fail to respond to standard therapy.

Electrocautery of skin lesions
Although I've only seen cautery being done in the operating room, this is a modality that can be employed in the office setting. It can be useful to remove moles, with the advantage of better hemostasis and so can be a good option when there is a greater risk of significant bleeding. It is also useful for getting rid of annoying spider veins and telangiectasia. 

Equipment:

• Alcohol wipe
• Local anesthetic
• 1-mL syringe with 30-gauge needle
• Electrosurgical unit (ESU)
  • This must include a smoke evacuator (HPV and HIV have been detected in smoke from this procedure)
  • Various electrode tips (depending on procedure), reusable or disposable
  • Antenna (or grounding) plateHandpiece for electrode tips (devices can be finger activated from the handpiece)
  • Foot pedal to activate the handpiece (useful for delicate surgeries to avoid compromising hand precision trying to also activate the device)
  • Movable cart
• Mask
• Nonsterile gloves
• Silver nitrite (or Monsel's solution if not working on the face)
• Antibiotic ointment
• Adhesive bandage

Procedure: Proper technique will depend in part on knowing how to use the device you will work with. Basic settings range from "cutting," "cutting and coagulating" or "cut and coag," and "coagulation." Basically, there is more hemostasis toward the coagulation setting side, but also more scarring (although if too low for the tissue being worked on, this could lead to less smoothness in the cut, and a more unsightly scar). The intensity of the electricity can also be adjusted to modify the power of the instrument,  so it can be tuned for the procedure to be effective while also limiting any excess force. This is a procedure that requires proper training and practice. Preparation before and care after the procedure is much the same as for other lump and bump procedures (see above).

​Skin scraping for fungus determination
This wannabe procedure involves a scalpel, so I'd say it "makes the cut." It was also lovely to encounter the description for this simple yet useful procedure in the Canadian Family Physician, the journal I read the most. The article is called, "Microscopic Potassium Hydroxide Preparation" and it was published in 2014 as part of a series called, "The Top Ten Forgotten Diagnostic Procedures," an initiative to teach family medicine residents about useful diagnostic procedures that are on the brink of extinction. Makes sense, I have only seen this procedure being done very rarely despite the multitude of times there's a diagnostic dilemma regarding yeast vs something else. I think the thinking is that empiric treatment with antifungals is of such little harm, it's okay to just give it a go without really knowing. But this can lead to treatment failure, onerous application and cost of antifungal therapies, and a delay in resolving the problem if it is not in fact a fungal infection. Of course, some fungal infections will clinically be very convincing of this, in which case this procedure would not need to be done. But, for those times in which there is diagnostic uncertainty, it makes a lot of sense to me to check a scraping for fungus under the microscope in real-time to inform clinical decision-making. Note that the use of a Wood's lamp is an alternative procedure that can be done before opting to do a scraping. 

Equipment: 

• Small scalpel blade
• Microscope slide and cover glass
• 20% potassium hydroxide (KOH)
• Gauze
• Microscope with 10 × and 40 × objectives

Procedure: 
As always you start with obtaining consent, and then gather equipment, position and drape the patient, and don personal protection. There is no aftercare needed for this procedure, but if the procedure does not reveal evidence of fungal infection, you should send the scrapings for fungal culture in case the sample collected is just not representative. Here is the meat in the middle:

1. Collect scrapings of the area of interest. This can be done very gently with a scalpel blade, possible with a blunter object such as a tongue depressor if the patient is not very cooperative.
2. Place the specimen on a clean glass slide. Add 1 drop of 20% KOH.
3. Place the cover glass on top of the slide and gently press to get rid of any air bubbles. Blot excess solution from the finished slide preparation with the gauze.
4. Place slide on the microscope stage and start with a low-power (10×) examination. To make epithelial cells visible, reduce illumination by lowering the condenser.
5. Examine for fungal structures such as hyphae or yeast. If any look suspicious, use the 40 × setting (high-dry objective) to investigate further, as hyphae or budding yeast suggest fungus

The article provides this photo of a positive finding under the microscope:

​Subungual hematoma release
Subungual hematomas aren't a significant concern, at least by themselves, but they can hurt like a B and if large, could suggest a fracture of the underlying bone in the finger or toe. For any significant hematoma, getting an xray before trephination would be the way to go. It's also only really helpful if a patient presents within 48 hours of when it began, as there is no evidence to show that trephination after this time makes a difference at all. Trephination should also not be done by the general practitioner if there are any complicating features, such as signs of infection, extensive nail-bed injury, or evidence of fracture. These patients should extend get a referral to a hand surgeon. Here is an example of a subungual hematoma that could be safely decompressed by the general practitioner, ideally from the distal end of it so as not to risk damage to the lunula (part of the nail bed matrix).

Equipment:

• Electrocautery device or insulin syringe 

Procedure:

1. Consent, patient prep, and putting on personal protection. You know the drill.
2. Perform a complete neurovascular examination of the digit along with examination for any injury to the extensor tendon. Inspect for nail fold disruption or signs that the hematoma is not just a simple hematoma.
3. Trephinate to open the subungual space. (Pretty much making a hole in the nail.)

Drainage acute paronychia
The information in this post gets credited to a fabulous Emergency Medicine website called Life in the Fast Lane.  Some gold nuggets by the Emergency Medicine Nurse who wrote the post:

• Paronychia is an inflammatory involvement of the fold of the nail. 
• Pus, erythema and swelling develop between the nail and nail fold causing throbbing pain and discomfort.
• The most common cause is direct or indirect trauma to the cuticle or nail fold.
• The most common organism involved in paronychia is Staph aureus

Equipment: Whatever you need to perform a digital anesthetic block (procedure to be explained, stay tuned), a scalpel, gauze, saline, a syringe and any associated supplies for irrigation, and a bandage +/- antibiotic ointment.

Procedure: All the usual, and then following:

1. Drain the paronychia by making a longitudinal incision parallel to the nail edge across the nail fold to release the pus, under a ring block anesthetic.
2. Mop out the cavity
3. Soak the digit in a saline solution and irrigate away any debris. Then dress the digit with an antibacterial or simple dressing.
4. There is no evidence that antibiotics are any better than incision and drainage, but patients with severe paronychia with tracking cellulitis require admission for intravenous antibiotics. For patients not admitted for intravenous antibiotics, consider discharging them home on oral antibiotics, with encouragement to elevate the affected digit. Ideally they should have the area inspected by a healthcare professional in 24-48 hours after the procedure is done.

Now just imagine this was a patient who came to you, and you can do something to make it better right away! Brilliant.

Partial toenail removal; Wedge excision for ingrown toenail
For whatever reason, these are listed as separate procedures under the list of core procedures that I am expected to be able to perform as a family physician, although the latter is really a reason (and probably the most common one) to do a partial toenail removal, so I have  lumped them together here. The other common reason would be to clip nails shorter when trying to debride a toenail of onychomycosis (toenail fungus), but in this setting, the procedure is as simple as trimming a nail as short as possible (the part with fungus doesn't have as much sensation, and you basically trim the nail as far back as you can while not causing pain). Another less common reason to trim a nail back is in the setting of trauma and partial traumatic nail avulsion. In this setting, you would want to trim the nail back just until it is not likely to catch (if the nail is oriented in a funny direction).

Equipment:

• Anesthesia and supplies for ring block along with adjunctive local anesthesia
• Chlorhexidine and supplies for soaking digit
• Blunt nail elevator
• Nail splitter
• Hemostat 
• Iris scissors
• Petroleum jelly or antibiotic ointment
• Nonadhesive dressing and bandage +/- supplies for changing dressing at home
• Open toed-sandal (patient's own) to wear home

Procedure:

• Consent, gather supplies, position patient.
• Anesthesia in a digital ring block (stay tuned), with additional local to ensure area is frozen to the max (this is a very painful procedure otherwise)
• Soak digit in antiseptic solution, which can be done while awaiting full freezing effect. Poke under nail bed of distal digit with sharp (ex: tip of iris scissors) to ensure frozen. (Note that it is good practice to always ensure good freezing somehow before starting any procedure for which anesthetic is given.)
• Insert blunt tool to separate the nail from nail bed (no longer ouchie because freezing), only including the edge of the nail if this is a wedge resection for an ingrown toenail, until you reach the proximal nail groove. Repeat this separation of the nail from surrounding tissue on the lateral nail fold and on top of the nail at the proximal nail fold.
• Once the nail is bluntly separated on all three sides, a nail splitter is used to cut the nail longitudinally. The freed edge of nail is then pulled out with the hemostat, and any residual epithelium can be removed with the scissors.
• Once the nail is removed, cover the nail bed with petroleum jelly or an antibiotic ointment, covered with a non adherent dressing, and bandage only lightly with gauze to allow for some swelling. Bleeding after the procedure is usually minimal.
• Advise patient to keep extremity elevated for 2-3 days to minimise pain associated with swelling that can occur. The patient should also change the dressing daily for about 7 days until the skin heals over, soaking the digit in warm water to facilitate easy removal of the dressing the first one to two days post-procedure. There is expected to be a gelatinous film over the nail bed when the dressing is removed. Patients can clean this off with a cotton swab and dilute hydrogen peroxide, then reapply the lubricant of choice and nonstick dressing/gauze wrap.

For all the visual learners:

Removal of foreign body, ex: fish hook, splinter, or glass
If there's something alien that is penetrating your skin, it's best to eject it from the mothership. Foreign bodies can obviously be painful, but they can also pose a serious risk for infection. Naturally, living in Canada means lots of splinter injuries with all the lumberjacks hard at work (:D), but now that I'm out on the West coast, fish hooks are also a thing (and beware of the ones with barbs on the end, tricky little buggers). Being in the downtown East side means I also need to be on the lookout for shattered glass. Okay I'm being lame, but these are three common types of foreign bodies that can inadvertently get under the skin from trauma. This year, I pulled out a piece of tree from a snowboarder who crashed into the bush while carving his way down Cypress mountain. He came into his family doctor's office for this, not the emergency department, so you just honestly never know what might walk in the door.

Really, foreign body removal is part of the process of good wound debridement (see above), so I won't belabour the topic here. It is important to highlight the need to ensure tetanus prophylaxis whenever a wound is penetrated by a foreign object. As well, if a patient complains that a wound feels as though something is in it, heed that sensation; if nothing can be seen, a plain xray can be your friend - even glass is radiopaque as long as the shards are larger than 2 mm. And while xrays are friendly, anesthesia is even friendlier - a digital ring block can make all the difference to ensure proper wound exploration under proper lighting +/- magnification. Irrigating with drinkable tap water is just as good as saline, and better in the possible dirty wound (per the mechanism of injury on history) because the pressure with saline syringe irrigation can further embed foreign material. 

...Sorta worth a splinter or two.

Pare skin callus
Calluses and corns and common benign skin thickenings on the feet that are physiologic adaptations increased pressure to that region of the body. Often, they arise because or poor-fitting shoes, abnormal gait, or underlying bony problems (commonly neuropathic joints as a complication of long-standing and poorly controlled diabetes). Sometimes corns in particular can be a bit difficult on first glance to differentiate from a wart, but you'll notice that warts obscure the natural skin lines ("toe prints" if you will), while these lines tend to be more pronounced with purely hyperkeratotic skin. After paring them down, you'll also see an absence of the dark specks normally within the central area of a wart (these are punctate capillary thromboses; the wart virus basically causes small clots in the surrounding capillaries).

Equipment:

• No. 15 scalpel blade
• Salicylic acid plaster/ointment
• Supplies for the dressing/dressing changes

Procedure:

• Along with all the other procedure basics (consent, documentation, and everything in the middle), the gist of corn or callus treatment is debulking it with a scalpel (this is not at all painful because this skin is keratinised epithelial cells, which does not have any nerve endings) and then applying salicylic acid treatment until the remainder of the hyperkeratotic skin has sloughed off. (Note that the use of salicylic acid therapy is contraindicated with patients with decreased sensation to the area - if the applied acid patch shifts and the patient doesn't feel this, it could lead to damage to perfectly healthy tissue)
  
• After being debulked with a scalpel, that first application of salicylic acid should be undisrupted ideally for 2-3 days straight, so the affected part of the foot will need to be kept dry so the salicylic acid continues to stay and work at the site. After this 2-3 day period, the patient can return for one another bout of skin paring. After this, the patient can continue to manage at home with daily salicylic acid and nightly removal with filing or pumicing any residual raised skin. The corn/callus should be resolved by two weeks after initial therapy; if not, the patient should return to see their treating physician. 
• For lesions that recur or that or recalcitrant to the above therapy, consider ordering an xray to look for underlying bony deformities 

Infiltration of local anesthetic
Finally, I will now go over the basics of how to provide local anesthesia. The only absolute contraindication to giving a patient local anesthesia is a history of previous allergic reaction to anesthetic, which is extremely rare, but you should always ask, just as when prescribing any other medication.

Equipment: 

• Personal protective equipment: gloves (nonsterile), mask, eye protection
• Antiseptic solution (ex: chlorhexidine)
• Syringe (10-30 mL, depending on how much local is needed)
• An 18 gauge needle for drawing up the anesthetic
• A 25-30 gauge (2.5-3.75 cm long) needle for injecting the anesthetic
• Local anesthetic of choice (ex: 1% lidocaine with epinephrine)
  • Consider using 2% rather than 1% lidocaine when the area needing anesthesia is in a limited space that cannot afford as much intradermal solution in order to achieve the same degree of freezing effect. Conversely, a 0.5% lidocaine solution is available when greater area is needing to be anesthetized and there is concern that the maximum dose of anesthetic would be exceeded before properly freezing the full extent of what is needed.
  • Maximum dose of 1% lidocaine with epinephrine is 7 mg/kg (4.5 mg/kg without epinephrine). Always figure out maximum allowable dose prior to starting for the patient in front of you.
  • Bupivacaine has a longer duration of action compared to lidocaine, but it is limited by the maximum allowable dose, which is much less than lidocaine at 3 mg/kg with epinephrine or 2 mg/kg without epinephrine. It would probably be nice to use if only a small quantity of freezing is needed. Bupivacaine 0.25% = lidocaine 1% in strength.
  • The old rule of thumb was never to use epinephrine for "nose, toes, fingers, ears". This theoretical myth has been debunked in clinical trials, and specialists who operate regularly on these body parts use epinephrine when anesthetizing them.

Procedure: 

1. Obtain consent (this should include warning patients about the short burning sensation that occurs when the anesthetic is first deposited, and that it is normal to feel ongoing pressure but not pain during the procedure)
2. Position patient supine or seated comfortable (some patients can get vasovagal and faint, so they should be in a position that would allow them to faint while protecting them from falling over should this occur)
3. Don personal protective equipment and gather other needed supplies
4. Consider what can be done to improve patient comfort. Some tips include:
   1. Don't draw up the anesthetic from the bottle with the large bore needle in front of the patient. The size of this needle may scare them (note that the needle used to deposit the anesthetic in the skin is much smaller). 
   2. Warm the anesthetic to room temperature and buffer with bicarbonate to decrease burning sensation on injection.
   3. Freeze the skin with ice or a cold pack prior to injection (in kiddos, an EMLA topical anesthetic patch can be put on an hour before the procedure to numb the skin)
   4. Inject slowly and use smallest quantity needed (but not so much that you may compromise good anesthesia)
   5. When freezing wounds, inject into the already traumatised tissue rather than puncturing nearby undamaged tissue. When multiple injections are needed, insert the needle into previously anesthetized areas whenever possible.
5. Cleanse the skin
6. Inject the anesthetic
   1. Insert the needle as deep as needed, and before pushing on the syringe to infiltrate the area with anesthetic, first withdraw to ensure you have not entered a blood vessel (much greater risk of toxicity when injecting into the bloodstream rather than the surrounding tissue).
   2. Then, deposit the anesthetic while at the same time withdrawing the needle (this also prevents depositing the anesthetic into a blood vessel).
7. Wait for the anesthetic to take effect (about 1 minute for lidocaine, and 5 minutes for bupivacaine)
8. Test that the anesthesia is sufficiently effective (pin prick or gentle forceps pinch). If not, add more (watching your maximum allowable dose)
9. Dispose of all sharps (I haven't explicitly talked about this in the above procedures, but this is also a standard step in any procedure containing sharps, such as scalpels and suture needles. There are special yellow containers for sharps in all healthcare facilities.
10. Include anesthesia details in any procedure note (note what choice of anesthetic was used and how much of it was deposited)

*Although highly unlikely, it may be useful to know that phentolamine is an antidote and can be used to reverse the effects of lidocaine if ischemic complications develop. This would be extremely rare. I have never heard of this being done, and have never even been taught that this is something I should know by any attending physicians with whom I have trained to give local anesthesia.

Digital block in finger or toe
Performing a digital block is an alternative method of providing local anesthesia when performing procedures on fingers or toes. It is a method of providing sufficient anesthesia to an area that is limited for space to deposit enough anesthetic agent for sufficient freezing. The procedure and equipment needed is much the same as for providing standard local anesthesia. 

The technique for performing a digital ring block using the two-injection dorsal technique is as follows: 

1. Pronate the patient's had with fingers extended
2. From the dorsal aspect, insert the needle at the border of the metacarpal head.
3. Raise a small wheel with anesthetic, then advance the needle anteriorly and slowly until resistance is felt at the palmar dermis (or needle tip causes a bulge on palmar side). Inject 2-3 mL of local here.
4. Withdraw the needle while depositing another 1 mL of anesthetic.
5. Repeat at the other border of the metacarpal head of the same finger.
6. Document cap refill and gross neurological exam before and after performing the ring block.

Incise and drain thrombosed external hemorrhoid
Left until the "bottom" of this post, this is a variation of the I&D for abscesses, only it is an I&D for a blood clot rather than a collection of pus. Hemorrhoids are common, and thrombosed external hemorrhoids (painful, tender, swollen, bluish lump at the anal orifice) can be a source of significant pain, although are easily "rectified" with an in-office I&D procedure, usually done within 48 hours of onset of pain because after this the pain starts to subside anyway. In the same "vein," perianal skin tags can also be excised, although this is mostly done for cosmetic purposes as they are asymptomatic (on occasion patients may experience pruritus from them). Patients should generally be advised that this procedure, like any, is not without risk, and so is generally not recommended. 

Equipment:

• ​Local anesthesia (ex: lidocaine 2% with epinephrine), 27-gauge 1.5-inch needle, 3 mL syringe
• Fine tissue forceps
• Scalpel blade (No. 11)
• Sharp scissors
• Mosquito hemostats
• Antiseptic solution (ex: chlorhexidine)
• Personal protection (gloves, gown, mask, eye protection)
• Patient may take NSAID about an hour or so before the procedure
• Electrocautery or silver nitrate sticks

Procedure:

1. Obtain consent (risks include: perianal abscess, chronic fissure, perianal cellulitis, bleeding or hematoma)
   
2. Anoscopy to ensure hemorrhoid originates below the dentate line (to be reviewed in another post)
3. Personal protection
4. Position patient in the left lateral decubitus position
5. Cleanse the perianal area with antiseptic solution
6. Anesthetize under the base of the thrombosed hemorrhoid with 2-5 mL of local anesthetic
7. Using the elliptical excision approach, excise an ellipse over the thrombosed hemorrhoid and evacuate all clots and control bleeding with electrocautery or silver nitrate
8. Postprocedure advice
   1. Sitz baths two to three times daily for 1 week.
      
   2. Oral analgesics, topical anesthetic cream (ex: lidocaine ointment), and gentle laxatives (ex:PEG) are helpful.
      
   3. A follow-up examination in 4 weeks.
      
   4. Preventing recurrence by treating constipation (usually the cause)
      

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Provide proficient surgical assistance

Today was the last day of my Obstetrics & Gynecology rotation at St Paul's Hospital, and am I ever glad to be done. It was hard work! I did enjoy it, at least parts of it, but I will not miss waking up at 5 AM every morning to round on the obstetrical ward. My alarm is set for 7:30 tomorrow morning, heaven!

At this point in time, I do feel I want to deliver babies (a concept I considered violent and unholy before starting residency), but I have no interest in being a surgical assist (with the exception of assisting with emergency c-sections in women for whom I am providing peripartum care). I can do it, as I did for a vaginal hysterectomy today (after which I was invited back by the surgery to provide further assistance, but was saved by the bell of my pager to asses a woman in labour), or for the laparoscopic hysterectomy and bilateral salpingoopherectomy I assisted with yesterday, but it is not my cup of tea. However, being a medical student means taking part in all aspects of medicine even in areas that are your least favourite, for basic learning and exposure. And if you are a family medicine resident, it pretty much means to do that all over again. Partly it makes some sense, as more exposure to all aspects of medicine help to nurture the well-rounded primary care practitioner. I've made it through my month of obstetrics and gynecology, and now I'll have two weeks of general surgery to conquer, my last 2 weeks of necessary time in an operating room in residency (and possibly ever). It is what it is. On the other hand, while it is my natural inclination to sigh and begrudge the whole process, I want to instead choose to face these next two weeks with an attitude of opportunity. If I use these two weeks strategically, I could really get a lot out of practicing sewing skills in the operating room and managing really sick patients, so I am told by my senior colleagues. 

In preparation for providing assistance in the OR while in medical school, I encountered this article online that simplified the process. Despite the fact that it was written for medical learners in the UK, and hence has various details that are irrelevant when preparing for nuances of the Canadian OR, the concepts are all very well the same, and I was glad to have encountered it ahead of time. The whole website, Geeky Medics - albeit designed more so for the medical student level - provides great intros to various clinical approaches in medicine. 

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Assess and manage pre-operative medical problems which affect surgical care (ex: cardiorespiratory disease, diabetes, medication)

The point of preoperative assessment is to look for risk factors that increase a patient’s risk of complications associated with surgery. After assessment, the clinician then attempts to reduce or eliminate, when possible, identified risks. This essentially involves optimising chronic disease management and identifying and mitigating other previously unrecognized risk factors. Along with attempting to reduce risk, it is also important to recognize and convey to patients that no matter how much risk can be reduced prior to surgery, it can never be entirely eliminated. There are always risks associated with surgery, although with comprehensive preoperative care, it is believed that these risks can be significantly reduced. In my last post I outlined a basic approach to preoperative assessment. Here I will review some key perioperative management strategies for common medical problems that may affect surgical care.

Cardiorespiratory disease

1. ​Optimize control of the underlying disease as much as possible, as would be done even if no surgery was planned. Order investigations to characterize degree of illness or to assess for complications if the results may affect management.
2. For patients with acute exacerbations of chronic disease processes (ex: acute exacerbation of congestive heart failure or of chronic obstructive pulmonary disease) or who develop a respiratory infection, delaying surgery until the exacerbation or infection has resolved is standard of care. Prescribe antibiotics and/or steroids if and when indicated.
3. For patients with high risk features of coronary artery disease (CAD), consider preoperative coronary angiography and possible revascularization prior to surgery. This will depend on the urgency of the planned surgery and the degree of CAD. Consult cardiology.
4. Encourage smoking cessation, ideally at least 4-8 weeks preoperatively, to significantly decrease associated postoperative complications.

Diabetes mellitus

1. ​Patients with type 2 diabetes mellitus who do not take insulin are generally advised not to take their oral hypoglycemic drugs on the morning of surgery.
2. Patients who require insulin perioperatively will be managed with an insulin infusion, in accordance with institutional protocols. 
3. Because of complications due to blood sugar levels, patients with diabetes are generally scheduled to have their operations done earliest in the day, prior to patients without diabetes. 
4. Once a patient is able to eat food again postoperatively, their usual method of glycemic control is reinstated. If the patient was on a perioperative insulin infusion, the patient must be given their first dose of subcutaneous insulin prior to discontinuing the insulin infusion (the half-life of IV insulin is just too brief; this overlap helps to avoid erratic blood glucose control during the transition back to injectable insulin).

Perioperative medication recommendations (general rules of thumbs, always unless otherwise indicated)
*See UpToDate article, Perioperative medication management for further details

1. Cardiovascular meds
   1. Continue up to and including the day of surgery: beta-blockers (substitute IV formulation  when NPO), calcium channel blockers (no IV formulation needed when NPO), statins
   2. Continue up to the day of surgery, but discontinue the morning dose: diuretics
   3. Discontinue the night before surgery (unless it is used for heart failure and the risk of hypotension is low): ace inhibitors and angiotensin-receptor blockers
   4. Discontinue ASA 7 days before surgery (if patient is taking for a cardiovascular indication, which is the only evidence-based reason to take it, consult cardiology for perioperative recommendations).
   5. The decision of if and when to stop and resume anticoagulant medications depends on the individual patient's risk of thromboembolism vs hemorrhage. Patients with significant risk of thromboembolism and those for whom you may be more cautious to stop anticoagulation include those with atrial fibrillation, a prosthetic heart valve, or those who have been diagnosed with thromboembolism within the preceding 3 months. Consider delaying surgery if the patient's risk of thromboembolism is only transiently elevated. Depending on the surgery, the risk of hemorrhage can also be significant. Depending on surgical and patient specific factors, this can vary significantly. Consider Internal Medicine consultation. If the decision is made to stop anticoagulation perioperatively, consideration must be given to bridging with low molecular weight heparin if the patient takes warfarin.
   6. Post-operatively, can resume any cardiovascular medications available in parenteral formulation while NPO 
2. Pulmonary medications
   1. Inhaled bronchodilators: Continue up to and including day of surgery (can use nebulised forms if inhalation difficult in the immediate postoperative period)
3. Gastrointestinal medications
   1. Proton pump inhibitors and H2 blockers: Continue up to and including day of surgery (substitute IV formulation for prolonged NPO state)
4. Endocrine medications
   1. Oral hypoglycemic agents and insulin (see above regarding perioperative management of diabetes mellitus)
   2. Oral contraceptives and hormone replacement therapy: Continue up to and including day of surgery if undergoing procedure with low to moderate risk of venous thromboembolism. Stop 4-6 weeks preoperatively if surgery poses higher risk (if premenopausal, counsel on alternative method of contraception and obtain pregnancy test immediately prior to procedure)
   3. Glucocorticoids: If patient has taken prednisone 20 mg/day or greater (or equivalent dose of another glucocorticoid) for more than 3 weeks during the last 6 months preoperatively, it can be assumed that their hypothalamic-pituitary-adrenal axis is suppressed, and stress dosing glucocorticoids is needed.
5. Psychiatric mediations
   1. Continue up to and including day of surgery. For patients at high risk of psychosis/agitation, IV formulation can be used. If no IV formulation, consider need to use medication from another class to address symptoms if needed while NPO.

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Manage routine pre-operative and post-operative care

While I am currently on my Obstetrics & Gynecology rotation, there isn't often a lot that needs to be done in terms of pre-operative and post-operative medical care. This is because women undergoing OB/GYN surgery are often otherwise healthy young to middle aged women. However, next up will be my General Surgery rotation, so I need to be prepared to assess for and manage perioperative complications in patients who have a bit more going on. 

Management of surgical patients begins in the preoperative period, ideally well in advance of any surgery they are going to have so as to best optimise their health pre-surgery. Optimising their health means to do 2 things:

1. Screen for diseases the patient it as risk for, which if left unnoticed and untreated could lead to complications during or after surgery (ex: cardiopulmonary disease, anesthesia risk factors, and others)
2. Optimize the control of any medical conditions that have already been diagnosed

It is important to start the pre-operative assessment with complete history. Elements that are particularly important to include in the pre-op history include:

1. Patient's functional status 
   1. Basically what matters for surgery is if the patient has exercise capacity  ≥4 METs (metabolic equivalents). 4 METs is equivalent to climbing up a flight of stairs, walking up a hill, walking at ground level at a brisk pace, or performing heavy work around the house. If the patient can do these things without stopping to rest, they may have less capacity than 4 METs and may warrant further assessment by stress testing (to look for evidence of coronary artery disease).
2. Patient's baseline risk of having a bad reaction under anesthesia
   1. Has the patient ever had general anesthesia, and if so, have they ever had any complications? Having had general anaesthesia without any prior complications means the risk of future complications is extremely low. If the patient has not had general anesthesia, asking if a family member has had a bad reaction to anesthesia is the next best thing. A rare genetic (autosomal dominant) phenomenon called malignant hyperthermia can occur with some patients, and it can be life-threatening. If a patient has had a family member with a scary reaction to anesthesia, the patient needs further assessment prior to receiving general anesthesia.
   2. Obstructive sleep apnea (OSA) is a common problem that is under-diagnosed, but that can lead to problems upon recovery from anesthesia. If a patient has OSA, it is important to optimize management of this pre-operatively. If the patient is not known to have OSA, the best screening tool out there to look for it is the STOP-Bang questionnaire (see below). Patients who screen positive should have further assessment with a polysomnography (seep study), which is the gold standard way of diagnosing OSA.
3. Complete record of the patient's past medical and surgical history, specifically looking for the presence or absence of the following diseases:
   1. Heart attack, irregular heartbeat, of heart failure
   2. Bleeding disorders or a family history of bleeding disorders
   3. Asthma, COPD, or other chronic lung disease
   4. Stroke or seizure
   5. Arthritis, pain, or stiffness of the neck and/or jaw
   6. Thyroid disease
   7. Diabetes mellitus (clarify whether the patient is insulin-dependent or not)
   8. Liver disease
   9. Kidney disease
4. Gather an accurate medication record, including anything taken over-the-counter, and any complementary or alternative medications. It is equally important to ask if the patient "self-medicates" with any other substances, and get down to the nitty gritty specifics (knowing the details can really make a difference to risk stratifying them).

Credit to the UpToDate article, "Preoperative medical evaluation of the adult healthy patient."

After you've gathered the above history, doing a focused physical exam is next. This includes the following elements: 

1. General inspection 
2. Vital signs (in full, including BMI*) *Note that while obesity is not a risk factor for surgical complications per se, it is a risk factor for postoperative venous thromboembolism and poor wound healing.
3. Cardiovascular assessment
4. Pulmonary assessment
5. Abdominal exam
6. Peripheral vascular exam

After the clinical assessment is complete, consider using this nifty risk calculator to stratify the patient's likelihood of having a perioperative complication.

After clinical assessment, you can move on to informed investigations based on the assessment. Consider ordering (if you know an indication, not by default) any of the following investigations:

1. Laboratory measurements: Hemoglobin, platelet count, electrolytes, blood glucose or HbA1c, LFTs, renal function, hemostasis testing, urinalysis, pregnancy testing.
2. 12-lead ECG
3. CXR
4. Echo
5. C-spine xray
6. Others, depending on the medical conditions and risk factors an individual has

After the full clinical assessment, with the results of any necessary investigations, you can develop your management plan to optimize any medical issues as previously known or as detected based on your pre-operative assessment (ex: getting blood glucose levels better controlled in a patient with diabetes). Next on the to-do list is to communicate any perioperative risk factors to the patient, surgery team, and any other relevant care providers. This will help the patient and care team decide whether or not to proceed with the surgery given the risks, benefits, values, and specific circumstances of the individual patient. If the patient is to proceed with the operation, a detailed care plan will need to be outlined to optimize patient outcomes before and after the surgery. Common issues to work out will be when to stop and start certain medications such as anticoagulants, and what the strategy will be after surgery to try to prevent them from developing a clot (a common post-op complication, we think about this in everyone who undergoes any surgery that keeps them bed-bound for a little while)

Post-operatively care consists of monitoring the patient as they recover, checking for any signs of complication, and encouraging a quick return to their usual functioning, because this leads to better outcomes. 

There is a well-known mnemonic for the medications you want to think about providing to the post-op patient if indicated: the 5 Ps. I've added a couple of extra Ps to include make it a completely useful mnemonic for me to remember not only some basic drugs to think about ordering to improve patients' comfort in the discomfort that is the post-op period, but also to remind myself of the most common concerns I want to check in about as the patient is recovering.

1. Pain/dyspnea
2. Prophylaxis (DVT)
3. Puke (nausea)
4. Poop (constipation)
5. Pass out (insomnia)
6. Physical exam (vital signs, ins&outs, labs)
7. Preexisting medical conditions

And then, on the surgical ward, they get sent home faster than you can say "no bedside manners."

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Assess and manage surgical disease including referral to surgical specialties as needed

Key Feature 6a: Given a patient with a life-threatening cause of acute abdominal pain (ex: a ruptured abdominal aortic aneurysm or a ruptured ectopic pregnancy): Recognize the life-threatening situation. 
Skill: Selectivity
Phase: Diagnosis

Key Feature 6b: Given a patient with a life-threatening cause of acute abdominal pain (ex: a ruptured abdominal aortic aneurysm or a ruptured ectopic pregnancy): Make the diagnosis
Skill: Clinical Reasoning
Phase: Diagnosis

Key Feature 6c: Given a patient with a life-threatening cause of acute abdominal pain (ex: a ruptured abdominal aortic aneurysm or a ruptured ectopic pregnancy): Stabilize the patient
Skill: Selectivity, Clinical Reasoning
Phase: Treatment

Key Feature 6d: Given a patient with a life-threatening cause of acute abdominal pain (ex: a ruptured abdominal aortic aneurysm or a ruptured ectopic pregnancy): Promptly refer the patient for definitive treatment. 
Skill: Selectivity
Phase: Diagnosis, Referral

I have not had the unfortunate experience of ever encountering a patient with an acutely life-threatening cause of abdominal pain. In fact, over the duration of my residency and my only occasional training in critical care/emergency, I may never encounter this. So I don't want to cop out on this, but I also don't want to delve into detail that will probably never be too clinically relevant for me. What I do want to know is what I would need to do to help try to save a patient's life if I am the physician who encounters a patient with an acutely life-threatening cause of abdominal pain. Here is what I feel I need to know to manage such a situation:

1. Recognize the life-threatening situation: With an acutely life-threatening cause of abdominal pain, the patient will likely either present with a complaint of acute abdominal pain, or else they may present in a decompensated state as a consequence of the underlying etiology (ex: the patient may be unconscious secondary to hypotension resulting from a massive bleed into the abdomen from a ruptured AAA or ectopic pregnancy). For patients who may be less able to localise or communicate their symptoms, the physical examination would be expected to reveal a peritonitic abdomen.
2. Make the diagnosis: In a patient with a life-threatening cause of abdominal pain, I need to make the call. Now I think it is certainly important to have an understanding of the different signs and symptoms associated with different etiologies for what could be going on, but rather than focus on this, I think it is more important to recognise that in this situation, a working DDx is more important than an accurate Dx. If a patient develops peritonitis from a perforated organ, of course knowing which organ was perforated, say, will only improve successful resuscitation. But regardless, in order to react urgently, we need to move on to stabilising the patient and saving their life, which is not amenable to a detailed workup if the etiology for the life-threatening abdominal pain is not overtly clear. So to me, this key feature is really about having a working DDx that takes into account patient risk factors (ex: in the elderly man with cardiac risk factors this must include the possibility of a ruptured AAA, and in the female of reproductive age this must include the possibility of a ruptured ectopic pregnancy). 
3. Stabilize the patient: ABCs. Although I won't outline the steps of the ABC emergency response algorithm here, this is the time to call them into action. In the setting of life-threatening causes of abdominal pain, there may very well be a bleed in the abdomen, and so circulation may be compromised and resuscitation efforts may centre around this. In the setting of acute abdominal pain and signs of hypovolemia (see two posts back for signs to look for), the patient should be suspected of having a bleed in their abdomen. As resuscitation efforts are underway, as part of this process, ordering investigations to determine the cause, severity, and consequences of the presentation should help refine the working DDx.
4. Promptly refer the patient for definitive treatment: In the setting of an acutely life-threatening cause of abdominal pain, making an urgent referral to the most appropriate surgeon is critical. The working DDx comes into play here. If suspicion of a ruptured AAA is at the top of the differential, an urgent consult to vascular surgery would be in order. If one is most suspicious of a ruptured ectopic pregnancy or another urgent gynecological cause, an urgent consult to an obstetrician-gynaecologist would be indicated. And if the cause of the life-threatening abdominal insult is undifferentiated, or if there aren't any more specialised surgeons available at the centre you are working, then an urgent consult to general surgery would be warranted.

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient's cultural and gender contexts, will be able to...

• Describe how the presentation and management of disease in children differs from adults
• Assess and manage atypical presentations of common medical conditions in the elderly
• Diagnose the common acute and non-acute disease entities requiring surgical treatment

Key Feature 1b: Given a patient with abdominal pain, paying particular attention to its location and chronicity: Generate a complete differential diagnosis (ddx).
Skill: Clinical reasoning
Phase: Hypothesis generation, Diagnosis

Key Feature 4: In a patient with acute abdominal pain, differentiate between a surgical and a non-surgical abdomen. 
Skill: Clinical reasoning, Selectivity
Phase: Physical, Diagnosis

Key Feature 5: In specific patient groups (ex: children, pregnant women, the elderly), include group-specific surgical causes of acute abdominal pain in the ddx. 
Skill: Clinical Reasoning, Selectivity
Phase: Hypothesis generation, Diagnosis

A 13 year old female presented to clinic with her mother today concerned about acute abdominal pain. She localised the pain as being midline in the lower abdomen. What is my ddx?

Like my previous post regarding the categorisation of acute vs chronic abdominal pain, sometimes (oftentimes) we encounter patients who challenge our clinical ability to categorise symptoms. Certainly this is true with pediatric patients, as their report of symptoms, if they are even old enough to verbally report symptoms, can be challenging to decode. Their inexperience with the pain of a headache may be entirely new, and perhaps associating feeling sick with feeling sick to their stomach, they may point to their tummy when you ask them where there pain is. Or maybe some kiddos actually feel sick to their stomach when they have a headache. The possibilities are endless, and without a reliable way to confidently know where pain or other manifestations of disease is originating from on history, as treating physicians we need to maintain a healthy dose of suspicion in searching for the culprit(s). As their own demographic, children also present with different probabilities of disease, and when it comes to abdominal pain, this is as true as any other undifferentiated symptom. 

My abbreviated ddx for pediatric abdominal pain (informed by the LMCC learning objectives) depending on the area to which the pain is localised (if they are old enough to be able to localise and communicate this information) is as follows:

• Epigastric pain
  • Gastroesophageal reflux disease
  • Peptic ulcer disease
  • Biliary tract disease
  • Pancreatitis
• Lower abdominal pain
  • Appendicitis
  • Mesenteric adenitis
  • Inguinal hernia (incarcerated)
  • Inflammatory bowel disease
  • Gastroenteritis
  • Constipation
  • Gynaecological causes in pubertal children
  • Urinary tract  infection
• Generalised pain
  • Peritoneal inflammation
  • Bowel (infantile colic, obstruction)
  • Malabsorption
  • Inflammatory bowel disease
• Flank pain
  • Nephrolithiasis
  • Pyelonephritis
• Functional abdominal pain

Of course, this list is not exhaustive, but it does prompt me to consider some of the most common diagnoses in pediatric patients, as well as important ones not to miss, including the ones that require urgent or emergent surgery. And when I encountered that 13 year old female in clinic today who was able to reliably tell me that she was having midline lower abdominal pain, I was able to use this ddx to inform my clinical data collection, my springboard to  collect pertinent negatives to arrive at a working diagnosis (which for this patient was constipation). I don't know that I was correct in reaching this conclusion, or that it was the only thing contributing to the pain, but my attending concurred with this conclusion, and it helped me look for the absence of findings suggesting a worrisome not-to-miss condition. If I cannot feel confident about localisation in a pediatric patient, then I can simply broaden my ddx to include all common and worrisome pediatric diagnoses. And if that still is unsatisfactory, I can consider the more extensive ddx I have for adult abdominal pain (which is still relatively abbreviated, but does take into consideration most bodily systems that may be sources of pain).

For completeness, here is my ddx for acute abdominal pain (adult patient, also informed by the LMCC objectives):

• Upper abdominal pain
  • Acute hepatitis, hepatic abscess
  • Biliary tract disease
  • Gastroesophageal reflux disease
  • Peptic ulcer disease, gastritis
  • Pancreatitis
  • Splenic infarct, splenic abscess
  • Referred cardiothoracic pain
  • Musculoskeletal pain
• Lower abdominal pain
  • Appendicitis
  • Mesenteric adenitis
  • Diverticulitis
  • Incarcerated hernia
  • Inflammatory bowel disease
  • Bowel obstruction
  • Renal colic
  • Urinary tract infection
  • Ectopic pregnancy
  • Pelvic inflammatory disease
  • Ovarian (torsion, ruptured ovarian cyst)
• Diffuse pain
  • Generalised peritonitis
  • Ruptured abdominal aortic aneurysm
  • Ischemic bowel disease
  • Gastroenteritis
  • Irritable bowel syndrome

And my ddx for chronic abdominal pain (adult patient, also informed by the LMCC objectives):

• Upper abdominal pain
  • Hepatic disease
  • Biliary disease
  • Ulcer and nonulcer dyspepsia (ex: heartburn)
  • Gastric cancer
  • Pancreatic disease
  • Referred cardiothoracic pain
• Lower abdominal pain
  • Bowel disease
    • Inflammatory bowel disease
    • Diverticular disease
    • Irritable bowel syndrome
  • Genitourinary disease
    • Pelvic inflammatory disease
    • Benign or malignant tumours
    • Endometriosis
    • Urinary tract disease

To elaborate a bit further on inclusion of surgical causes of acute abdominal pain, it is important to know which diagnoses require surgical referral, be it after a bit of a workup to confirm the diagnosis, or more urgent or emergently if the patient is seriously unwell or with signs of peritonitis*. In the pediatric patient, for example, this could mean first doing an ultrasound** to rule out appendicitis if you think it is possible but not highly likely as the cause of the abdominal pain, or it could mean ordering imaging concurrently as you urgently consult general surgery if you think an acute appendicitis is in fact likely to be the underlying etiology for the pain. For any case in which a patient is presenting with peritonitis and a broad working differential for acute abdominal pain, a consult to general surgery is indicated. If the working differential is more focused, given the clinical presentation and patient-specific risk factors, then the surgeon to consult will depend on suspected etiology and local specialist accessibility, and may warrant consultation with general surgery, gynaecology, urology, cardiac surgery, vascular surgery, or otolaryngology. Of course, consultation with a nonsurgical medical specialist may also be warranted given the working diagnosis, such as a gastroenterologist, nephrologist, or infectious disease specialist, among others. The timing of when to involve such specialists must be driven by the urgency of the situation in combination with the working differential, be it to provide diagnostic clarity when there is confusion or to administer therapy that is not in the general practitioner's scope of practice.

*In a patient presenting with acute abdominal pain, it is particularly important to examine the patient's abdomen to decide if it is "peritonitic" (otherwise known as a surgical abdomen). Peritonitis is the inflammation of the peritoneum, the sac that encases much of our abdominal organs, and is an ominous finding that suggests surgical intervention is needed. Features most suggestive of peritonitis on physical exam that warrant urgent surgical consultation, in the order in which they would be assessed as per the Inspect-Auscultate-Percuss-Palpate (IAPP) approach to the abdominal exam as is standard medical school teaching, include:

• "Bump the stretcher test"
  • Literally you pretend to accidentally bump the stretcher and see if the patients respond with pain. It's not nice if there really is peritonitis, as any sudden movements can cause significant pain, but if it helps you to figure out they have peritonitis, I think the pain caused by bumping their stretcher is far outweighed by the pain of a missed diagnosis of peritonitis.
• Percussion tenderness
  • ​Another test of something that should otherwise not cause any measurable degree of discomfort, in a patient with peritonitis, even gentle percussion on the abdominal wall can produce pain out of proportion to the tap, increasing the likelihood that the patient has a peritonitic process occurring in their abdomen.
• Guarding/rigidity
  • Guarding and rigidity are phenomena whereby patients tense their abdominal wall muscles in order to protect the underlying organs in the abdomen. On examination, the abdominal wall feels firm. The difference between guarding and rigidity is that in the former, the muscle tension is voluntary, such that if you can get a patient distracted, maybe by asking them questions that take their mind ever-so-momentarily off the fact that you're feeling their tender abdomen, the abdominal wall becomes softer. Rigidity, on the other hand, is involuntary contraction of the abdominal wall musculature. With a peritonitic process, the irritation of the peritoneum causes a reflex contraction of the muscles in processes not requiring conscious contraction. So neat. As you may expect, rigidity has a much greater likelihood ratio in predicting the presence of peritonitis than does guarding, but even guarding does increase the likelihood of peritonitis so is important not to overlook if full on rigidity is absent.
• Rebound tenderness
  • ​To elicit this finding, you push down on the abdominal wall as you do when palpating in general, and then you release. In the force of pushing in on a peritonitic abdomen, this will likely cause the patient significant pain already, but the likelihood of the patient with acute abdominal pain having peritonitis is actually greater if the pain on removal of the force inward on the abdomen (the pain on rebound) is worse.

**A tangent on how the management of disease in children differs from adults: A consideration that a  physician must have when working up a pediatric concern is how the potential for harm and benefit of various interventions is different from that of an adult or geriatric patient. For example, the potential for harm from repeated CT scans could increase a person's risk of cancer down the road, and having hopefully much more time to live and bear secondary mutations possibly related to effects of radiation, the risk to benefit ratio of performing CT scans in pediatric patients is not the same as in older patients. Although the harm of a single CT scan is not so significant if it means possibly saving a life, it is something to consider if your pre-test probability of ominous disease is low. The converse is also true for the elderly or other patients that have risk factors for true and serious pathology: where the weight balances on the risk vs benefit scale shifts. The same general rationale regarding management decisions applies to considering interventions in pediatric patients as compared to other demographics, and the wise physician will remember to consider that the benefit to harm ratio of anything we choose to do or abstain from doing will differ depending on the individual before us.