‪The calm before the storm is not calm. Even while the wind is not blowing, there are signs: dark clouds, sore joints, frightened animals, news from the neighbors. ‬There is a little time to prepare, to tie things down, secure doors, warn others. The well-seasoned recognize the signals readily, and the more junior learn quickly.

‪At least, I assume that this is true, that this analogy is apt, that these comments are accurate and make sense. I’ve never lived on a farm, the few tornado warnings leading to an hour in my basement have been based on man-made sirens rather than nature’s, and the signals I follow are much more commonly from Twitter, where subtlety is rarely a concern. I assume these signs are present based on television and movies, books and metaphors, and old stories from old experts. Still, it fits well with the overall theme here, so let’s assume without loss of generality that even if the “calm” is not as hectic as the storm itself, it’s far from silent.

The Simpsons: That’s a false analogy! No, it’s not. It’s apt. Apt!

We’re accustomed to this in medicine. Astute observers have an edge, especially if they recognize the early signs often taught to them by their elders, sometimes taught to them by unfortunate experiences. They are experts not just at general medical care and diagnoses, but at finding patients who will get worse before they get better. These are the patients who appear comfortable though tachpneic and will need intubation in a few hours, the patients with new anastomoses who have unexplained tachycardia on postoperative day 3, and the patients who “just don’t look right” and need the judgment of someone more senior. These are patients who are giving warning signs that allow early intervention, and who will have a much better outcome if they get it. These patients may be described (retrospectively, when they do get worse) as experiencing “failure to rescue.” (This is not the more strict research and hospital quality definition, but rather in the more broad spirit.)

This failure to recognize early signs, this inability to take appropriate actions when they could prevent a worse outcome, lies with individual providers but also are affected by the culture of medicine and more broadly. Much comes with experience, especially recognizing patterns that have previously resulted in devastation. With luck (and good teaching), this recognition can come from the experiences of others rather than repeating their mistakes. However, this requires the unusual combination of insight, humility, curiosity, and responsibility in both the provider and their educator. It must be encouraged in the greater system using tools such as the morbidity and mortality conference that seeks improvement rather than blame, education that encourages sharing personal experiences alongside robust data, and culture that encourages collaboration between multidisciplinary groups with diverse knowledge and experiences.

Recognition of early warning signs and acting proactively, unfortunately, is not uniformly encouraged. We are accustomed to positive such experiences in medicine being praised as a “good save”. When such recognition does not bear fruit—when the tachypneic patient improves with ambulation and incentive spirometry, or the tachycardic postop patient gets better with a change in pain medication—juniors are still often commended as being “on their toes”. However, in much of our society, experts describing warning signs and advising caution are called paranoid or even accused of perpetuating a “political hoax”. Should those warnings be heeded but no disaster results (even if it was prevented by the early recognition), cautious experts are further chastised as having “overblown” the seriousness of the problem.

I am not an expert in COVID, epidemiology, or disaster medicine. I am, however, an expert in treating acute medical and surgical problems, with a special interest in adapting to unusual situations that arise seemingly without warning. I do not know whether the pandemic will result in a frustrating few weeks or in a major societal change. I do know that the best knowledge I can gain comes from the experts who are speaking, and especially from those in areas like Italy who are experiencing the epidemic at this moment. And I know that if we are somehow able to forestall ventilator shortages, elective surgery cancellations, and the loss of thousands of lives, then those who are speaking up now will not be rewarded for their contributions, but instead could suffer a significant loss in their (public) reputations.

They have capably recognized the massive drop in barometric pressure, and are sending us to our storm cellars. We can and should praise them for their warnings, whether or not COVID is near-apocalyptic. And, above all, we should listen.

Massive Transfusion & the 6 W’s

A presentation I give frequently for our divisional “core lecture series”, this basic introduction to massive transfusion protocols and the science behind them is appropriate for a general surgery resident or senior medical student audience. Share and enjoy.

Penetrating Abdominal Trauma

Our residents needed a readable (and relatively brief) chapter on “penetrating trauma”. Though there are plenty of books on the subject, finding a reasonable shorter work that wasn’t entirely useless was difficult. So, with the help of the generous license at and this previous awesome work by Charles Krin and Karim Brohi, I took a shot at putting one together. It updates the 2004 article a bit and adds a section on management of specific penetrating organ injuries. It’s appropriate for residents, it’s pretty rough, and there’s lots of complex stuff it leaves out (you might consider it ATOM Lite, really light). But hey, it’s free. Share and enjoy.

The latest version will always be posted on this page. If you find issues or have questions, please get in touch with me on Twitter or by email. Thanks!

Download “Penetrating Abdominal Trauma: Evaluation & Management”, version 20170821-2:

  1. as an editable Word document
  2. as a formatted PDF

A Few New Things

I’ve had some wonderful projects come to light this week, and despite the obvious shameless self-promotion, I’m gonna write a bit about each of them here. This isn’t a list for bragging, and is far from a simple CV addition, but I’d like to talk a little about each, including some of the struggles, joys, and thoughts that led to them.

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