The Healing Power of Farmers Markets

Posted on May 6, 2023 by marylbrandt

Rituals have great power, but some more than others. For me, going to the Farmers Market has become a ritual that is almost as important as the food I buy there. So I spent some time this morning pondering why…

It’s outside. Sun, clouds, breeze. Sometimes a little cool, sometimes too hot… but always the season that matches the fruits and vegetables being sold that day.

There is music. And dancing… people dancing with children, children dancing alone, folks dancing in their wheelchairs.

Everyone is happy. Seriously. Not a dour face anywhere!

There is delight in the colors, odors, and tastes.. It’s beautiful… and that sensual beauty evokes all kinds of good emotions – delight, joy, and even awe.

It anchors you to the season. We don’t have peaches in January at the farmer’s market. So when they show up in May it’s a day of celebration! Eating what is being grown in the season keeps you somehow anchored to life around you and, according to some traditions, is better for your body. It’s certainly better for the planet, since this is food grown within miles of where it’s sold… not half way across the world.

You develop relationships with the people that grow your food. Lisa’s new tortoise gets a spectacular salad every day, so we chat about his salads and her goats. I get to practice my French with the Congolese farmers who grow their produce on an inner city farm developed to provide new refugees a place to farm. Some of the vendors know my name, most of them know and recognize me with a smile (even if they don’t know my name), and all of them are happy to share how to prepare their food and what’s happening on the farm.

And then there is the food. There is no question it’s often (but not universally!) more expensive to buy your food at the farmer’s market, but for the reasons above it’s worth it. But there is one other reason … which is probably the most important reason of all.

How to Harvest and Store Potatoes -- Harvest to Table

Photo credit

One of the very first times I went to a farmer’s market, I bought potatoes. I remember distinctly thinking that it would not be worth the extra money because “it’s just a potato”… but I did it anyway. Every potato I had ever bought in a store tasted the same as every other potato … so I didn’t expect these to be any different. Wow… I was SO wrong. A potato that has been pulled out of the ground the day before you cook it is absolutely amazing. A light went on. Fresh food raised in smaller quantities by people who are devoted to doing it tastes better. It just does.

Plant It Forward CSA shares ready to be picked up

There is most likely a farmer’s market near you if you live in a city, but if there isn’t you have a other options (The USDA Local Foods Directory is a wonderful way to find farmers markets, gardens, and local farms near you if you need help. )

CSAs (Community Supported Agriculture). Google “CSA’s near me” to find farms that make up boxes with small portions of anything they are harvesting that week to distribute to people who have signed up with them.

Community Gardens. If you love to garden (and you can spare a few hours every once in a while) you might want to actively participate – it’s also pretty soul soothing to dig in the dirt and grow your own tomatoes. But it’s also worth asking if you can buy any produce that isn’t otherwise promised.

A local farmer or neighbor who has a big garden. You don’t know unless you ask. Offering to buy some of their produce might end up being a win-win. They may have too much produce, need a little extra income, or both. And you end up with fresh produce and a relationship with the person who grows it!

To Those Whom Much Is Given…

Posted on April 10, 2023 by marylbrandt

96. everything is power-law distributed

97. everything is power-law distributed

When someone writes about 137 life hacks and two of them are a) identical and b) something you have never heard of, you can’t help but dive down that rabbit hole…

Photo credit

So, what is a power-law distribution?

A power-law distribution is the statistical description of change that is proportional to the power of the change, in other words, change that is logarithmic, not linear. One of the classic examples of a power-law distribution curve is how income is distributed in society.

Although there are many uses for this principle in the world of finance and economics, power-law distribution can also serve as a mental model to help us understand ourselves, each other, and the world we live in.

Photo Credit

For those who are healers, or who are studying to be healers, there are three uses of this mental model that I think are particularly relevant:

1) Hacking your studying

2) Investing in your future

3) Understanding inequities

Hacking Your Studying

I unknowingly wrote about power-law distribution when I explained the “forgetting curve” in this post: “How to Ace the NBME Shelf Exams, In-Training Exams and Your Boards”. I recommend you read the entire post, but the take home message is this: Cramming never works if your goal is learning how to heal. What works? Repeating information you want to learn at least five times in gradually increasing intervals (ok, you type A folks… get out the spreadsheet).

Photo credit

The best time to plant a tree was last year. The second best time is today.

The power-law distribution also helps you understand why you need to start investing for your future – today. The chart below is what happens if you invest $100 a month starting as a new grad and keep doing it for 35 years (assuming a 6% return on your investment)

p.s. Here’s the website to do this calculation with different variables- investor.gov calculator

This kind of “investment strategy” also works for exercise. Wow, do you gain strength and fitness fast at the beginning… and how sad that it only takes about six weeks to lose most of what you previously gained if you stop (both are examples of power-law distribution). Like financial investment, investing in your body with small “doses” of consistent exercise is the best strategy. For most of us who work in a hospital, the amount of walking we do at work is close to the recommended minimum for fitness (#GoodNews). Just accumulate a few more minutes at a higher heart rate (take the stairs, speed walk to the next consult, etc), add some body weight strength exercises like pushups, and you are good!

Photo credit

Understanding Inequities

Investing for the future and how to hack your studying are important, but there is an even more important use for this mental model… It can help us better understanding the inequities in our society and in our work.

It’s easier to accumulate resources if you start with more. This principle is why young faculty members with limited mentorship or disproportionate service at home or at work end up not advancing. It’s why marginalized youth without resources to obtain education or connections struggle to break free from the cycle of violence and poverty. It’s why those who “have” (money, education, privilege) end up with disproportionate success (or access to care) when compared to those who started with less. Yes, there are exceptions, but they are just that… exceptions to the powerful force of power-law distribution.

Photo credit

There are hundreds of examples of power-law distribution including the beauty of fractals like the pattern in this beautiful head of romanesco broccoli or the curve of a beautiful seashell. (It’s worth looking at the list… some of them are fun!)

Maybe Alexey Guzey is right…

96. everything is power-law distributed

97. everything is power-law distributed

A Hundred Words for “Tired”

Posted on March 1, 2023 by marylbrandt

It has been said that the Inuit people have a hundred words for snow. When you live in a dangerous environment, it’s important to learn the variations of snow to survive. But, when you look into the origin of the “hundred words for snow”, it turns out it’s not exactly true – Inuits don’t have more words for snow than other languages…Their detailed understanding of snow is a lived, not spoken vocabulary.

The same is true for those who spend nights awake working in a hospital. We, too, have a lived vocabulary that includes hundreds of subtle variations of fatigue, even though we don’t have words to describe them. (The closest I’ve come to being able to describe this fatigue is in “sleep equivalents”, specific events or things that makes you feel like you have had more sleep than you actually did. For example, a shower after being up all night can give you the equivalent of anywhere from 20 to 60 minutes of sleep depending on how tired you are. Brushing your teeth after a hard night of call is usually 5-10 minute sleep equivalent. A good strong cup of coffee can be as much as 45 minutes of sleep equivalent – although it’s important to titrate it so you don’t end up with anxious jitters instead of just being awake.)

Knowing how to manage this level of fatigue it is part of medical training. (Don’t get me wrong… I’m not advocating that trainees must get tired on a regular basis to “learn how to manage it”) Learning to successfully manage the fatigue of long days and nights on call hinges on two things and both have to do with deliberate choices.

Learning not to trust your first instinct if you are sleep deprived is the first important lesson. Even if it’s a drug you know well, or the chest x-ray looks ok, stop and be deliberate. Consciously review the data, look at the options and, for really important decisions, ask someone to look at the situation with you.

The second lesson in managing fatigue is maybe even more important. The bone deep fatigue of medical training is not solely the result of sleep deprivation. When you stay up all night you also lose the liminal spaces of waking and falling asleep, the threshold between night and day. In scientific terms, this means there is a major disruption of your circadian rhythms. But it’s more than just physiology. The drowsy moments between sleep and being awake take place in the liminal spaces of dawn and dusk. We lose more than orientation to daylight when we lose this liminal space. The Irish poet and priest John O’Donoghue, teaches that liminal spaces are moments and places where the spiritual touches the finite. By losing the profoundly important rhythm of rest – including these liminal spaces – we end up physiologically, psychologically, and spiritually unmoored.

You have to be deliberate here, too. By trial-and-error work to find the things that ground you, the things that help you recover in a deeper way than just catching up on the sleep. Make lists of anything and everything that helps you recover from call for the times you are too tired to remember or choose. Look at those lists before you leave for your call day and choose something to do for yourself when you leave the hospital the next day. It might be going to the gym for a light workout, having a great cup of coffee in a cafe, a slow, grateful walk outside, playing with a pet, a hug from a loved one…or finding a way to “play” outside.

May the sacrifice of time and sleep you make for others come back to you as joy … and may you find deep rest in knowing you make a difference in so many lives.

Why don’t we do the things that bring us joy?

Posted on November 16, 2022 by marylbrandt

All of us have a list of things we know we should do every day… and usually don’t. They shouldn’t be that difficult to fit into our day, but we somehow end the day holding our intentions and the struggle rather than the completed task. I’m not talking about the things other people need from you, or the requirements of jobs or school. I’m talking about the things that bring you joy (whether immediate or delayed), things that are really important to you.

Why don’t we do the things that bring us joy? The first step to conquer this paradox is to make a master list of the things that bring you immediate joy (e.g.prayer/meditation, reading, journaling, playing music, calling or writing to a friend you haven’t seen in a while, walking in nature, checking in with older relatives if it’s been more than a couple of days, learning something new, cooking for your family and/or friends) …and things that might be hard at the moment but will bring you joy in the long run (e.g. working out, organizing and cleaning your living spaces, working on a big writing project)

Once you’ve made this master list, acknowledge there is no way you are going to be able to do all these things in a day. It’s important to name these things, to make this list and revise it as new things are recognized… but it’s equally important to acknowledge that you are going to have to make some choices. Pick what you currently think are the two or three most important things on this list and make a covenant with yourself that you will do them “every” day. The “every” is in quotes because let’s be real… life happens. Promise yourself that you will do these things every day, but give yourself grace for the occasional day when it’s just not possible.

Photo credit

Next, pick a way to remind yourself and keep track of your progress:

Schedule them on your calendar. This is probably the best way to do this for most people, but you have to build in a “what if” plan. If for some reason you don’t accomplish it at the time you scheduled it, it doesn’t break the promise you made to yourself. Move it on the calendar, commit to doing it later, but don’t blow it off.

Keep a “routine checklist”. This is separate from any other to-do list you create. This is for you. Not the things you have to do for other people, but the things you are doing for yourself, the things that add goodness to your days.

Morning is best (if you can). There is an adage in finance that you should pay yourself first. In other words, the first thing you do with your paycheck is to put money aside for investment in your future. Time is no different. Doing the important things first, the things that are just for you, is an investment in the day and your future.

The power of streaks. Put an X on a calendar every day, like Jerry Seinfeld or get the app that lets you put the Xs on a digital calendar. (There are other streak tracking apps, too.) Alternatively, create your own visual record of a streak with Excel or a Word document. The power of a streak is that you become more and more invested in not breaking the streak as time goes on.

Final thought. We are all busy, and we are all tired. This era, more than most, is one of being pushed and pulled in so many directions and in so many ways. Take the time to identify the things that bring you joy. If that’s all you do, it will be a good start, because just making that list will make it more likely you will add joy to your days. When you are ready, make a real covenant with yourself, a promise that you will do the one, two or maybe three (no more that three!) things at the top of that list every day. And then, do your best. Give yourself grace when you stumble… and start over.

Rethinking “Exercise”

Posted on September 4, 2022 by marylbrandt

I recently read a book that changed the way I think about exercise…for real. It not only provided scholarly (but very readable) insights – it also made me feel less guilty about “not exercising” while giving me some new tools to think about caring for my body.

If you are in the 10% of people who exercise regularly without thinking about it, great. For the rest of us, here are my key takeaways from Daniel Lieberman’s book, Exercised.

Along with many other aspects of our daily life, exercise has been “medicalized”.

Every week in clinic, I talk to young parents who have been sent home from the hospital with instructions to feed their baby [xx] mls of formula every three hours. They set alarm clocks! They often end up feeding their baby when the baby isn’t hungry, and don’t give a little more when they know the baby is still hungry after they are fed. This is “medicalizing” food and it is not only silly, it can be harmful.

In our personal lives we medicalizing food (aka diets… which don’t work in the long run)…and we medicalize exercise. We have all learned the “dose” of exercise that is now recommended: 150 minutes per week of moderate exercise or 75 minutes/week of vigorous exercise (plus weight training twice a week). When you step back and think about it… really? The same “dose” for all of us? The same “dose” every week?

We evolved to be couch potatoes

Photo credit (and article on the origin of the term “couch potato”)

The struggle to exercise is normal! We are fighting evolutionary pressure to not waste energy, to move only enough to take care of our needs and the needs of our community. Our bodies haven’t changed over the centuries. What has changed is our environment, which has become so efficient that we don’t have to move as much to walk through our day. So how do we fight back against our programing to be couch potatoes while honoring the need to keep our bodies physically healthy?

Just move (which you already do)

“… if you are a typical person who barely exercises, it would take you just an hour or two of walking per day to be as physically active as a hunter-gatherer. (p. 19)

The average healer in a hospital easily meets the goal of walking for more than an hour a day, Congratulations! You don’t need to “go to the gym” for another hour! There are other reasons to exercise (you will have to find a way to lift weights and stretch), so don’t take this as carte blanche to ignore your need to be fit, but quit beating yourself up for not “exercising”.

Stand up.

Sitting for prolonged periods is not good for you, primarily because it promotes the slow burn of mild inflammation. You don’t have to medicalize this, either, but don’t sit without breaks. Just stand up, fidget, walk to the water fountain… whatever it takes to move.

Play.

Breaking a sweat doing something you love is not only good for your body, it’s also good for your soul (and your sleep). Reframe! Find something you love to do that will let you break a sweat. (Note, the key word is “let”, not “have to”). If it’s outside, even better, but just go play.

Even a little exercise can make you happier!

Learning Medicine #SmartNotes

Posted on July 18, 2022 by marylbrandt

What if I told you there’s a system that makes it easy to remember the things that you need to remember for exams, but also creates links that make it easy to study and understand the network of knowledge that you really need to learn to heal?

And what if you could start using this system beginning on the first day of medical school…or at the beginning of your PGY2 year… or wherever you are on this journey now?

Here’s how:

Step 1. Create a folder in Google Drive*

Step 2. Take notes. About everything.

Step 3. Put the notes in your digital folder, filed by date and time, identified by hashtags and keywords.

Step 4. Synthesize, summarize, and link.

Step 1: Create a folder in Google Drive*

Don’t panic. Yes… just one folder.

Mine is labeled “card file”. You can always rename it. Maybe start with “My digital brain”?

If you just can’t stand it, you can create sub folders based on an anatomic filing system (e.g. Appendix, Colon, Heart, etc) but trust me – no sub-sub folders!

*I like Google Drive because it’s very flexible and you can access it from any computer and your phone. There are other ways to store digital data that can work as well, like Evernote, OneNote, etc.

Step 2: Take notes. About everything.

Keep a notebook in your pocket, use paper out of the printer, use a white board, or dictate directly into Google drive… but just take notes!

This practice is a leap for most of us, but it not only leads to phenomenal learning, it fundamentally transforms how you interact with your day. There is power in a practice that makes you more present in your day. Every encounter, every lecture, every article you read becomes a potential adventure, a source for new insight and growth.

There are only two rules

Rule 1: One concept per note.

Rule 2: Write the note only one time – don’t rewrite or retype notes. (If its’ a paper note, take a photo, or create a pdf to file in your google drive.)

What kind of notes will go into this system?

Lectures. You know how to do this from other classes! Just because we call it “Grand Rounds” or “Path-Rad conference” doesn’t mean it’s not a class. Take notes!

Notes from Reading. Textbook chapters, articles, handouts…

SOP (Standard Operating Procedure). This one is key if you are in a procedural specialty. Keep a single “note” for each procedure and update it with new information as you scrub with new attendings. Put in links to good videos, photos from textbooks and anatomy books. Anything that will help you review what you know and have learned before you do the procedure again.

Milestones. The first time you….listened to a murmur, talked to a patient about their prognosis, did a Whipple.

Questions, thoughts… “Why isn’t there a way to diagnose malrotation that needs surgery (vs.nonrotation) with diagnostic imaging?”

What you learned from patients. Make it your goal to learn something from every patient you take care of. Write it down. Make sure it’s HIPAA compliant – no patient identifiers that someone else could decipher.

Sounds. Yes, you can digitally store recordings!

Summary Notes. One page summaries of complex ideas

Unanswered questions. Ideas for possible publications, future investigations, etc.

Step 3. Put the notes in your digital folder, filed by date and time, identified by hashtags and keywords.

File the notes by date and time + description e.g. 2022-07-18 1645 Creating a filing system for studying medicine.

Why?

Imagine… It’s the last year of your residency, it’s 2am, and you are admitting a patient with Hemophilia A who needs emergency surgery.

You open your phone, go to your folder and search for #Hemophilia… and you find these notes:

First year lecture on coagulation

Second year lecture on disorders of coagulation

Second year lecture on the pharmacology of factors given for the different types of hemophilia

Your summary notes on coagulation, coagulation disorders, and the meds used to treat them

Notes from a review article on caring for patients with hemophilia

Notes about that really cute 6 year old on your pediatric rotation who had hemarthrosis

Notes from Grand Rounds on your medicine rotation about disorders of coagulation

A lecture during your surgery rotation on pre-op preparation of patients with clotting disorders.

Notes from Sabiston’s Textbook of surgery on patients with Hemophilia

What you learned taking care of the diabetic hemophiliac who needed an amputation when you were an intern

Last years’ conference with the visiting professor who was an expert on Hemophilia B

Step 4. Synthesize, summarize, and link.

There are so many details in medicine that we often lose track of the big picture. That takes thinking, creating one page summaries of complex topics, and noticing connections.

Maybe it would be easier to show you rather than tell you. Let’s say you are in a lecture about how to read a chest x-ray. In your notebook (or on your computer) you are taking notes… lots of notes… how to tell what’s a pneumonia vs atelectasis, what different lung tumors look like, how to tell if the mediastinum is too wide. As a result, 2 years from now when you see a patient with a lung mass, you will be able to search your drive for “lung cancer” and these specific notes will come up.

But as you sit and think about this lecture, you’ll realize that in addition to the details, there were more general concepts that were important, too. For example, how important it is to systematically review every diagnostic image so you don’t miss the lytic lesion in the bone that was behind the big mass in the chest. (Link to my favorite study describing how this happens)

So you create a digital note that describes, in your words, how important it is to have a system to look at images. Which makes you remember that this is very similar to how we always follow a system to do a history and physical. So you search in your drive for the card you made about how to do an H&P and you link them, using the “insert link” command. And, as you look at your H&P card, you notice that you had already linked it to cards you made about Basic Life Support (BLS) and ACLS (Advanced Cardiac Life Support), two certificates you were required to obtain, both based on a system to not miss important steps in resuscitating patients. And suddenly you are interested in why systems like this make it so much easier, so you do a quick search and find a fascinating article on memory and learning (as opposed to memorizing).

This post represents a modification of the amazing Smart Notes system described by Sönke Ahrens in his book How to Take Smart Notes: One Simple Technique to Boost Writing, Learning and Thinking. I highly recommend it, especially if you are considering an academic career!

Other things I’ve written about studying in medical school and residency:

Studying for the In-Training Exam 2022-01-30

Study Tips for First Year Medical Students 2018-08-11

How to Succeed in Clinical Rotations (and residency, too) 2018-01-09

Top Ten Tips on Starting Medical School 2022-06-18

How to Ace the NBME Shelf Exams, In-Training Exams and Your Boards 2017-04-14

Advice for Graduates

Posted on June 15, 2022 by marylbrandt

The following is a guest post from my father, Professor Floyd Brandt.

At the time I decided to retire, I experienced two thoughts: First, I had been in a footrace for several years between retirement and obsolescence. The second thought was the closing line from Stephen Sondheim’s song Send in the Clowns — “Isn’t it rich, isn’t it queer, losing my timing so late my career.” Given the issue of obsolescence, I declared that my retirement was a trip from doing to being and then discovered that being is as challenging as doing, and often more so—learning to pause, meditate, and seek the joys of solitude requires new thoughts and habits.

Many, if not most, professors are inclined to think about what they would say in their Last Lecture and some even write it for the millions who will never read it and for students who will never remember it. My final lecture to my graduate classes could be divided into the pragmatic and the personal—I have included the pragmatic here:

After graduation, be your own professor. Keep asking questions. The quality of your life and the organizations you inhabit are dependent upon the quality of questions posed and answered.

During the interview with a potential employer, ask as carefully as possible, “What stories can you tell me about the company or organization”. If they have no stories, you may want to consider another company or organization.

As soon as possible, assemble a “Go to hell” fund equal to six months of salary available in case you need to refuse to engage in an unethical, illegal or extremely distasteful activity.

Attempt to locate the leaders in the organization who has real concern about defining the next decade.

Find out and then think about the years your boss was a teenager.

Begin to develop a flexible plan for the future. It is a truism that individuals and organizations that plan, seldom follow their plans, but they tend to perform better than those who do not plan.

Recognize the value of patience and silence. It usually takes a few years to achieve a top position in an organization.

No Time to Teach? Try This.

Posted on April 27, 2022 by marylbrandt

I’ve started a new practice as a medical educator that has been working so well that I thought I should share it.

Once (or twice) a day in every teaching hospital every service makes rounds and, while managing and treating their patients, the attending (and/or senior residents) teach.

https://middlemarch.com/film/making-rounds/

Inevitably, there are unanswered questions that come up as we discuss patients. Many of them are questions I don’t know the answer to, or are related to a hot topic that might have new information just published. Here are some examples of questions that have come up on rounds on our pediatric surgery service:

Are there new recommendations about how to manage gallstone pancreatitis and/or choledocholithiasis in kids?
What is the caloric content of the different formulas we prescribe?
What is the best way to calculate calorie needs for a burn patient?
How and why do you swaddle a baby?
How do you manage supplemental oxygen after you extubate a patient with severe facial burns?
Where does “second line” come from?

Typically in the past, each student and intern would be assigned one or two of these questions to answer. They would be expected to report back to the team the next day – which might or might not happen depending on how busy the day was (and if the attending remembered to ask them). But to be honest, this way of teaching has become harder with time. There is a post-call resident who is not there the next day, the students often have didactic sessions that are required so they aren’t there, and the day can get so busy that there isn’t (perceived) time to teach on rounds.

But it’s our responsibility to teach (the word doctor means teacher!). Teaching is also a powerful antidote for burnout because its so important and so meaningful. It was clear – I had to come up with a way to make this work in spite of the limitations created by our schedules and clinical responsibilities. So here is what I do now in addition to teaching on rounds:

During rounds we come up with one question per person (everyone, not just the students and interns).
Each person is responsible to answer their question via a group email that, as the attending, I start on the first day I’m rounding.
The answers are short and helpful – as though each person is taking notes for themselves. No PowerPoint presentations, no extensive diatribes.
The email answer is due before the next morning… but no one is allowed to stay up late to do this.

Here’s what was sent on our group email to answer the examples I listed above. (Disclaimer – These are unedited. Don’t use these for patient care unless you look things up yourself!):

What is the “board answer” for treatment of gallstone pancreatitis?

Usually mild as the stones pass spontaneously in the majority of patients but can be severe (even life-threatening) although this is rare. This is due both to fluid loss (equivalent of a severe burn) and to SIRS

initial Tx: Fluid resuscitation, pain control, nutritional support (oral when patients are subjectively hungry – low fat diet)
Surgery during the same hospitalization (Munoz, 2022) (Berger, 2020) (Noel, 2018)
ERCP only if there is cholangitis or persistent cholestasis (Schepers, 2020)

What is the “board answer” for treatment of choledocholithiasis.

First step: Is it asymptomatic or symptomatic (i.e. pancreatitis, cholecystitis, cholangitis)?
Emergency ERCP (<24hrs) for cholangitis, cholecystitis and/or pancreatitis with obstruction
Stones must be cleared. There is no benefit to waiting and there is a downside to waiting since there is always a risk of cholangitis or pancreatitis with a stone in place.
Most surgeons use pre-operative ERCP for known choledocholithiais followed by cholecystectomy, but ERCP at the time of cholecystectomy in adults (Rucci, 2018) (Cianci, 2021) and kids (Fishman, 2020) has been shown to be safe – and perhaps better.

Calorie content of available Tube Feed/Supplements:

Two Cal HN – 2 Calories/mL – high protein

Glycerna 1.2 – 1.2 Calories/mL – lower glycemic index

Nepro Carb Steady – 1.8 Calories/mL – high fiber, gluten free, for lactose intolerant

Impact Peptide 1.5 – 1.5 Calories/mL – supposedly decreases risk of enteral infection in surgical/trauma patient with peptide formulation

Vital 1.2 – 1.2 Calories/mL with 1.2g of NutraFlora per 8oz for gut health

Pediasure Peptide 1.5 – 1.5 Calories/mL – designed for those with malabsorption

Ensure Plus – 1.5 Calories/mL with 16g protein

Osmolite 1.5 – 1.5 Calories/mL – fatty acids for different digestive profile

Jevity 1.2 – 1.2 Calories/mL with 4g fiber/8oz and 1.9 NutraFlora for gut health

Kate Farms 1.5 Peptide – 1.5 Calories/mL – supposedly marketing for smaller tubes without needing to be watered down

Nutritional needs for burn patients

Calorie calculator is complex: https://burnstrauma.biomedcentral.com/articles/10.1186/s41038-017-0076-x/tables/1

2.5-4.0 g/kg/day protein for burned children vs 1.5-2.0 g/kg/day for adults

Fat should be less than 15% of total calories

Carbs 7g/kg/day for burned children

Where did swaddling begin and why do we do it? How do you swaddle a baby?

Etymology/History

Swath (a strip in a field or a strip of cloth)
1325 first recorded use in English – Cursor Mundi (Gött.) l. 1343 A new-born child..Bunden wid a suadiling band (OED)
Almost universal in the 18th century, with or without a cradleboard

Benefits of Swaddling (van Sleuwen, 2007)

Infants arouse less and sleep more
Soothes pain in infants
Prevents hypothermia
Decreases excessive crying due to stimulation

Adverse effects of swaddling (van Sleuwen, 2007)

Hyperthermia if not monitored
Increased risk of hip dysplasia
Increased risk of SIDS if prone
Promotes skin infections in hot, humid climates

Video showing three different methods of swaddling

Facial burns and airway management:

*The mortality associated with orofacial burns or smoke inhalation is related to the degree of lung damage, patient’s age, and the extent of the burn; it is not related to the method of upper airway control. Arch Surg. 1976

*In Facial burns, edema of the head and neck, supraglottic, and glottic areas is the most common cause of airway obstruction

Modified Tube for Endotracheal Airway Management of Children with Facial Burns Antonio G. Galvis, MD,

The team from this article designed a particular ETT setup

Treatment for postextubation stridor was required after 11 (37%) of 30 extubations, with five reintubations and one tracheostomy. The best predictor of postextubation stridor was absence of an airleak at the time of extubation (sensitivity 100%, positive predictive value 79%, p less than .001), followed by type of injury (facial burn vs. all others; sensitivity 64%, positive predictive value 88%, p less than .001).

Kemper KJ, Benson MS, Bishop MJ. Predictors of postextubation stridor in pediatric trauma patients. Critical Care Medicine. 1991 Mar;19(3):352-355. DOI: 10.1097/00003246-199103000-00012. PMID: 1999096.

What a second line means!

The “second line” refers to the spectators who join or follow the main line (usually the brass band) and contribute to the walking parade. This is what separates a second line from any other New Orleans parade: groups are not only welcome but encouraged to follow along, allowing the second line to grow as it marches. The term “second line” doesn’t only refer to the parade itself, it also speaks to the type of dancing you will find during those parades. “Second lining” is a highly recognizable strutting, chicken-like dance move that many people use to keep pace with the band. So “second line” is a term with many meanings; it applies to a type of parade, a part of the parade, and a dance move used within that parade.

Things I Wish I’d Known From the Beginning: OR Lights

Posted on March 29, 2022 by marylbrandt

One of my residents this morning thanked me for teaching her how to adjust the lights in the OR before a case. In fact, she said that since she had started this new practice that she hasn’t had to re-position the lights once while operating. There are so many minor details about the art of medicine that aren’t in books, so many things that make our lives easier…and that we wish someone had taught us earlier!

Operating Room Lights 101

Both lights should be positioned in the mid-line of the operative field – which means usually the mid-line of the table.

One of them should point straight down into the operative field. The second light should be either at the head or foot of the bed pointing into the field at an angle. If there are more than two, use them however it seems best.

Most importantly – You should position the lights BEFORE the procedure. Adjusting them after you start is always more difficult.

Operating Room Lights… Down the Historical Rabbit Hole

4500 BCE – Oil lamps

3000 BCE – Candles

1802 – Incandescent light invented by Humphrey Davy.

1850s – Operating rooms were built in the southeast corner on the top floor of hospitals to take advantage of natural sunlight. There were also four mirrors in the corners of the operating room to reflect sunlight toward the operating room table. (Wikipedia, Surgical Lighting).

1880s – Incandescent bulbs commercially available.

1920 – The scialytic (which means “dispersing or dispelling shadows”) light invented by Professor Verain in 1920 was the first design to direct light around the head of the surgeon. This allowed operating rooms to be moved from the top floor of hospitals. (Ersek, 1972)

1930s – Fluorescent lights commercially available

1962 – First LED light developed

“The light must be sufficient in quantity, must be directed into the proper places, and must be of such a quality that the pathological conditions are recognizable. Also the light cannot produce glare, which will serve to blind the surgeon, just as the high headlights of an oncoming automobile may incapacitate an automobile operator; and it is just as dangerous.” (Beck, 1971)

There are four factors to consider in optimizing illumination (reference)

Luminance = reflected light. Too much = glare = eye strain.

Volume. This refers to the need to have light in more than one plane, which is important because we operate in three dimensions (which is why there are always two lights). This is also why surgeons wear headlights or use lighted retractors.

Shadow management. This is why the position of the lights is important!

Temperature. Was much more of an issue before LED lights.

Setting the lights to set your intention

Positioning the lights before an operation will help you see more clearly. This simple act can also become a ritual and a reminder of why you are there… to heal.

When a Thought Won’t Let You Go

Posted on February 15, 2022 by marylbrandt

We’ve all been there (yes, all of us). Something happens and we can’t stop thinking about it. It can be a complication, a misdiagnosis, something that happened in a toxic work environment, a failed exam, a harsh word. Not being able to let go of these thoughts means you are a normal person who cares… but it is not comfortable.

It will stop. At the time you are caught in the spiral of rumination, it seems unending. But it can’t and won’t last forever.

You are not your thoughts. There are your thoughts (and this annoying thought in particular) and then there is “you”. Hold that thought (then see below).

Don’t make it worse by yelling. It’s human nature to try to push an uncomfortable thought or image out of your mind. But it doesn’t work. Yelling at yourself (in your mind) because you are not able to move past the thought/event makes it even worse.

Get curious. Berating yourself makes it worse, but there is a way to disarm the thought and even make it go away:

When the thought arises, just notice it.

Wait….if “you” are noticing it, then the thought isn’t “you”.

Exactly.

Every single time the thought arises, say to yourself “I’m thinking about it again.” But – and this is the most important thing – when you notice that the painful thought is back, you have to notice it without judgment. Not… “I can’t believe I can’t let go of this thought.”…or “Something must be wrong with me.”… Just “There it is again.”

Mindfulness. The practice of noticing without judgment is called mindfulness. There are good data that an informal practice of mindfulness helps when we find ourselves with a thought that won’t let go. A daily practice helps even more. Set aside just 10 minutes and sit still. Just notice everything that comes up, acknowledge it, and don’t judge. Ditto for the next thought, and the next, and the next…

Here are some links if you’d like to learn more about mindfulness:

If you only read one thing about mindfulness, make it this book: The Miracle of Mindfulness: An Introduction to the Practice of Meditation by Thich Nhat Hanh

Headspace is a fantastic app to help you learn mindfulness

Mindfulness for Beginners from Psychology Today